Neligan vol 6 chapter 09 main

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9

Flexor tendon injury and reconstruction

Jin Bo Tang

S Y N O P S I S

� Tendons transmit forces generated by muscles to move joints or to create action power. Flexor tendon injuries are common, but recovery of satisfactory function, particularly after injuries within the digital sheath, is sometimes diffi cult. Lacerated fl exor tendons should be treated by primary surgical repair whenever possible.

� The current trend of end-to-end surgical tendon repairs is to use multistrand core sutures (four-strand repairs such as cruciate, double-Tsuge, Strickland, modifi ed Savage, or six-strand repairs such as modifi ed Savage, Tang).

� In tendon repairs in the digital sheath area, a number of surgeons advocate that the A2 pulley can be released up to two-thirds of its length, and the A4 pulley can be entirely released when necessary and tendon repair is in the proximity of the pulley, given the integrity of the other pulleys. The release may reduce the resistance to tendon motion and the chance of repair ruptures. This technique is somewhat controversial.

� Postoperatively, early tendon mobilization should always be employed, except in children or in some rare instances; motion protocols vary greatly among different treatment centers.

� Repair ruptures, adhesion formations, and fi nger joint stiffness are major complications of primary surgery.

� Combined use of multistrand core repairs, release of constricting pulley parts, and well-designed postoperative combined passive and active motion protocols – that do not overload, but suffi ciently move the tendon – can help minimize adhesions, avoid repair ruptures, and restore optimal function.

� Secondary surgeries include tenolysis, free tendon grafting, and staged tendon reconstruction. Tenolysis is indicated when restricting adhesions hamper tendon gliding and soft tissues and joint conditions of the hand are favorable. Free tendon grafting is a salvage operation for failed primary repairs, delayed treatment ( > 1 month) of an acute cut, or lengthy tendon defects. Staged reconstruction is indicated in case of extensive scar formation or multiple failed surgeries. Preservation or reconstruction of major annular pulleys is vital to restoring function of the digits during these secondary surgeries.

� Closed ruptures of fl exor tendons usually require surgical repairs. � The success of fl exor tendon surgeries is very expertise-

dependent. A thorough mastery of anatomy and meticulous surgical technique are requirements for satisfactory restoration of function.

SECTION II Acquired Traumatic Disorders

Access the Historical Perspective section online at http://www.expertconsult.com

Introduction Tendons are composed of dense connective tissues that trans-mit forces generated by muscles to move the joints or to create action power. Functionally, the hand is dependent upon the integrity and ample gliding of the tendons. Among all the tendons in the body, those in the hand are most frequently subjected to injuries, due to their length and the varied nature of the activities of the hand. The pursuit of ideal repair tech-niques has drawn the attention of surgeons ever since hand surgery became a subspecialty. For over a century, fl exor tendon repairs have presented challenges to hand surgeons, and aroused enormous enthusiasm of clinicians and investigators.

Diffi culties in restoration of function of digital fl exor tendons relate chiefl y to the intricate anatomy of fl exor tendon systems: the coexistence of superfi cialis and profundus tendons within a tight fi bro-osseous tunnel. Frequent peri-tendinous adhesions jeopardize tendon gliding. Tendons within the synovial sheath (intrasynovial tendons) were once considered to lack the capacity for self-repair; therefore, inva-sion of adhesions from peritendinous tissues was believed to be a prerequisite in the tendon-healing process. 1 – 4 As the con-cepts regarding tendon-healing biology evolved, tendon cells have proved capable of proliferating and of producing colla-gens to heal the tendons eventually. 5 – 10 However, the tendon is innately low in cell density and growth factor activity, limit-ing its early healing strength.

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179Basic science

Basic science

Anatomy There are 12 fl exor tendons in the hand and forearm regions. They include fi nger and thumb fl exors and wrist fl exors. Finger fl exor tendons are the fl exor digitorum superfi cialis (FDS) and the fl exor digitorum profundus (FDP), and the tendon in the thumb is the fl exor pollicis longus (FPL). They originate from muscles at about the midforearm. Except for the index fi nger, the tendons of the FDP come from a common muscle belly. The tendons of the FDS originate from separate muscle bellies, which allow more independent fi nger fl exion. The FPL tendon arises from the volar aspect of the midportion of the radial shaft and from its adjacent interosseous mem-brane. Three wrist fl exors are fl exor carpi radialis (FCR) and ulnaris, and palmaris longus. Palmaris longus is absent in about 15 – 20% of the normal population. Wrist fl exion power is not affected by the absence of this muscle.

Within the carpal tunnel, nine tendons exist – four FDS, four FDP, and one FPL. The relationship of these tendons within the carpal tunnel is fairly constant. The FDS tendons to the ring and middle fi ngers lie superfi cially, deeper are the FDS tendon to the index and small fi ngers, and deeper still are the FDP tendons. The FPL tendon is located deep and radially adjacent to the scaphoid and the trapezium. After emerging from the carpal tunnel, the tendons enter the palm. At about the level of the superfi cial palmar artery arch, the lumbrical tendons originate from the FDP tendons.

The most intricate portions of the fl exor tendons are within the fi ngers, where the tendons glide within a closed fi bro-osseous sheath with segmental, semirigid, constrictive dense connective tissue bands present. The digital sheath forms a closed synovial compartment extending from the distal palm to the middle of the distal phalange. Proximally, the synovial sheath ends just proximal to the neck of the metacarpus, forming the proximal refl ection of the digital fl exor sheath. The FDS tendons lie superfi cial to the FDP tendons up to the bifurcation of the FDS tendon at the level of the metacar-pophalangeal joint (MCP). Then, FDS tendons become two slips coursing laterally and then deeper to the FDP tendons. This FDS bifurcation is in the A2 pulley area. This part of the FDS tendon also serves to constrain the FDP tendon; the FDS segment at bifurcation may be viewed as a structure functioning similarly to a pulley. Deep to the FDP tendon, the FDS slips rejoin to form Camper ’ s chiasm (a fi brous inter-weaved connection between two FDS slips), and distally insert on the proximal and middle parts of the middle phalanx as two separate slips. The FDP tendon inserts into the volar aspect of the distal phalanx. The FPL tendon is the only tendon inside the fl exor sheath of the thumb and inserts at the distal phalanx.

The digital fl exor sheath consists of the synovial sheath and interwoven condensed fi brous bands ( “ pulleys ” ). The syno-vial sheath is a thin layer of continuous smooth paratenon covering the inner surface of the fi brous sheath, providing a smooth surface for tendon gliding and nutrition to the tendons. The pulley system of the digital fl exor tendon is unique; it consists of annular pulleys (condensed, rigid, and heavier annular bands) and cruciate pulleys (fi lmy cruciform bands) ( Fig. 9.1 ) . 151 There are fi ve annular pulleys (A1 – A5),

In the early and middle 20th century, secondary tendon grafting dominated the repair of digital fl exor tendons. During this period, tendon implants were developed for staged tendon reconstruction. However, as the practice of primary repairs prevailed in recent decades, the number of cases indi-cated for secondary tendon grafting or staged reconstruction decreased drastically. Primary repair of injured digital fl exor tendons was pioneered by Verdan 11 and Kleinert et al. 12 in the 1960s and is the essential approach underlying current prac-tice. Current primary repairs and inception of early tendon motion were based on the recognition of the intrinsic healing capacity of tendons in the 1970s and 1980s by Lundborg, Manske et al. , and Gelberman et al. 5 – 10

Nevertheless, despite the widespread use of primary repairs, surgical outcome remained unpredictable, and some-times even disappointing. In the last two decades, major efforts were thus devoted to tackling this problem, with the goal of achieving consistently optimal outcome and minimiz-ing repair ruptures and adhesions. In this regard, a number of multistrand core surgical repairs – such as the techniques of Savage, Strickland, cruciate, Lim-Tsai, or Tang 13 – 19 – have been developed to replace weaker, conventional two-strand repairs. Subdivisions of zones 1 and 2 of digital fl exor tendon systems were proposed by Moiemen and Elliot, 20 and Tang, 21 who offer precise nomenclature when recording the locations of tendon cuts, discussing treatment, and comparing outcome. Surgical procedures to release critical parts of the pulleys have been advocated by Tang 22 and Kwai Ben and Elliot 23 to decom-press the tendon and free tendon motion. In the last few years, we witnessed reports in which repair ruptures were com-pletely avoided, with recovery of excellent or good function in most cases. 19,24,25 These recent reports represent remarkable steps towards satisfactory fl exor tendon repairs and highlight the promise of predictable tendon repairs ( Box 9.1 ).

Box 9.1 General tips for surgeons of fl exor tendon repairs

• Repairing fl exor tendons requires meticulous surgery built upon a thorough master of anatomy and biomechanics of the fl exor tendon system. Surgeons should know the anatomy in detail, including the length of major pulleys, characteristic changes in the diameter of the sheath, and tendon gliding amplitude

• Primary repairs should be performed by experienced surgeons whenever possible, or if a less experienced surgeon has to be the operator, before surgery the surgeon must review the anatomy of the fl exor tendon system, and understand every detail of the requirements of an optimal tendon repair

• The mastery of atraumatic techniques is essential for the operator. The outcome of the repair is very expertise-dependent: repair of tendons by an inexperienced surgeon is a frequent cause of tendon adhesions and poor function, thus should be avoided

• Conventional two-strand repairs are weak; stronger surgical repairs are preferable

• Complete closure of the tendon sheath is not a necessity. Venting of a part of sheath ( < 2.0 cm), including a critical portion of the pulleys, provides easy access to injured tendons, and decreases resistance to tendon gliding after surgery; this procedure does not lead to loss of digital function when other sheath parts are intact

• Surgeons should emphasize strong suture techniques and decreasing gap formation, which will lead to early active motion exercises and better outcomes


180 SECTION II • • Flexor tendon injury and reconstruction9

pulley is about 0.5 – 0.7 cm. The diameter of the fl exor sheath is at its narrowest at the level of the A4 pulley and in the middle and distal parts of the A2 pulley. The A2 and A4 pulleys are easily recognizable, because both are remarkably denser and more rigid than their adjacent fl exor sheath. The A1 pulley, with a length of about 1.0 cm, is located proximal to the A2 pulley; in some instances, both A1 and A2 pulleys merge to form an especially lengthy pulley complex. The A3 pulley is located palmar to the PIP joint, but it is very short (0.3 cm) and may be diffi cult to distinguish from the synovial sheath.

In the thumb, there are three pulleys (A1, oblique, and A2) with no cruciate pulleys ( Fig. 9.2 ) . The A1 and oblique pulleys are functionally important. The A1 pulley, 0.7 – 0.9 cm long, is located palmar to the MCP joint. The oblique pulley, 0.9 – 1.1 cm long, spans the middle and distal parts of the proximal phalanx. The A2 pulley is near the site of insertion of the FPL tendon, and is thin and 0.8 – 1.0 cm long.

The FDP tendon has two vincula: a fan-like short vinculum and a cord-like long vinculum. The short vinculum is located at the insertion of the FDP tendon ( Fig. 9.3 ) . The long vincu-lum connects the FDP tendon through the short vinculum of the FDS tendon to the fl oor of the palmar surface of the phalanges. The FDS tendon also has two vincula: one connect-ing to the proximal phalanx, and another at the insertion of the FDS tendon. Vincula carry blood vessels to the dorsum of these tendons, providing limited nutrition. Tendon insertion sites to bones also carry vessels into tendons over a very short distance.

three cruciate pulleys (C1 – C3), and one palmar aponeurosis pulley. 151,152 The A1, A3, and A5 pulleys originate from the palmar plates of the MCP, proximal (PIP) and distal inter-phalangeal (DIP) joints, and the A2 and A4 pulleys originate from the middle portion of the proximal and middle phalanges respectively. The broadest annular pulley is the A2 pulley, which covers the proximal two-thirds of the proximal phalanx and encompasses the bifurcation of the FDS tendon at its middle part. The A4 pulley is located at the middle third of the middle phalanx. The A2 and A4 pulleys are the largest among fi ve annular pulleys and have the most important function. The annular pulleys maintain the ana-tomical paths of tendons close to bones and phalangeal joints, thus optimizing the mechanical effi ciency of digital fl exion. The more compressible cruciate pulleys allow for digital fl exion to occur with condensation of the fi bro-osseous sheath at the inner part of fl exed fi ngers. This is called a “ concertina effect. ”

The length of the A2 pulley is about 1.5 – 1.7 cm in the middle fi nger of an average adult, and the length of the A4

Fig. 9.1 Annular pulleys (condensed, rigid, and heavier annular bands) and cruciate pulleys (fi lmy cruciform bands) are present in the fi ngers. There are fi ve annular pulleys (A1 – A5), three cruciate pulleys (C1 – C3), and one palmar aponeurosis pulley.

A5

A4

A3

A2

A1

Transverse metacarpal ligament

Vertical septa

Palmar

aponeurosis

C3

C2

C1

Fig. 9.2 Locations of fl exor pulleys of the thumb. There are three pulleys in the thumb: A1, oblique, and A2 pulley, from proximal to distal.

A2

A1

Oblique pulley

Abductor pollicis

Flexor (deep head)


181Basic science

According to anatomical features, the fl exor tendons in the hand and forearm are divided into fi ve zones, which offer the fundamental nomenclature for fl exor tendon anatomy and surgical repairs. 153 In the 1990s, the most complex areas – fl exor tendons in the digital sheath – were subdivided by Moiemen and Elliot, 20 and by Tang. 21 The zoning is described below, and its relation to the locations of pulleys is shown in Figures 9.4 and 9.5 : • Zone 1: from the insertion of the FDS tendon to the

terminal insertion of the FDP tendon

Fig. 9.3 Insertions and relative positions of the fl exor digitorum superfi cialis (FDS) and fl exor digitorum profundus (FDP) tendons and vincula. Each of the FDS and FDP tendons has two vincula, one short and one long. The relations of the FDS and FDP tendons are complex in the middle part of the proximal phalanx under the A2 pulley (zone 2C).

IIDIIC

IIB

FDP tendon Vinculum longus FDS tendon

Vinicula brevia

Vinculum brevia Vinculum longusA

B

Fig. 9.4 Divisions of the fl exor tendons into fi ve zones according to anatomical structures of the fl exor tendons, presence of the synovial sheath, and the transverse carpal ligament.

1

1

2

2

3

3

4

5

Fig. 9.5 Subdivisions of zones 1 and 2 of fl exor tendons in the fi ngers and their relations to the fl exor pulleys.

Subdivision of Zone 1

(Moiemen and Elliot)

Subdivision of Zone 2

(Tang)

1A 2A 2B 2C 2D1B 1C

• Zone 2: from the proximal refl ection of the digital synovial sheath to the FDS insertion

• Zone 3: from the distal margin of the transverse carpal ligament to the digital synovial sheath

• Zone 4: area covered by the transverse carpal ligament

• Zone 5: proximal to the transverse carpal ligament. In the thumb, zone 1 is distal to the interphalangeal (IP) joint, zone 2 is from the IP joint to the A1 pulley, and zone 3 is the area of the thenar eminance.

The subdivisions of zone 1 by Moiemen and Elliot are: • 1A: the very distal FDP tendon (usually < 1 cm), not

possible to insert a core suture • 1B: from zone 1A to distal margin of the A4 pulley • 1C: the FDP tendon within the A4 pulley.



for a very limited distance to become part of adhesions. Conceptually, extrinsic healing does not equal adhesion for-mation. However, it is extrinsic healing in the form of restric-tive adhesions that hampers tendon function.

The following fi ve variants (grades) of adhesions are seen clinically: (1) no adhesions; (2) fi lmy adhesions: formation of visible, fi lmy, and membranous tissue from tendon to outside tissues; (3) loose adhesions: loose and largely movable; (4) moderately dense adhesions: of limited mobility; and (5) dense adhesions: dense, almost immovable, and invading deep into the tendon.

The fi rst two grades do not affect tendon motion; the third affects motion mildly. Because the fourth and fi fth affect motion dramatically, those are the adhesions that surgeons seek to prevent. The density of adhesions relates to the tissues from which they arise. The adhesions arising from bones, periosteum, or major annular pulleys are dense. The density of adhesions can be altered to some extent by tendon motion. Some adhesion fi bers can be disrupted as well. Surgeons should do their utmost to preclude or minimize the formation of adhesions which will restrict tendon gliding.

Many strategies have been attempted or suggested to prevent adhesion formation, including medications, use of artifi cial or biological barriers, and chemical or molecular approaches, with varied results. However, few medications or barriers have become clinically routine. So far, the most effec-tive methods to prevent adhesions in clinic are meticulous surgery and early postoperative motion; the prime cause of adhesions is tendon repair by inexperienced surgeons.

Biomechanics of tendon repair and gliding Forces generated during normal hand action range from 1 to 35 N, except tip pinch, according to in vivo measurements. 154 Therefore, a surgically repaired tendon should be able to with-stand a tension of at least 40 N during motion, with suffi cient power to resist gap formation. The repair should be able to withstand cyclic loads under both linear and curvilinear load conditions. Laboratory tests have shown that conventional two-strand core repairs plus running peripheral sutures yield a maximal strength from 20 to 30 N 93 ; this is lower than forces generated during normal hand actions and explains why some repairs are disrupted during postoperative motion exer-cise. Studies showed that failure forces of four-strand repairs are around or beyond 40 N 16,65,94 ; six-strand repairs fail with loads over 50 – 60 N. 13,71,85

Many factors affect the strength of a surgical repair ( Fig. 9.6 ) : (1) the number of suture strands across the repair sites – strength is roughly proportional to the number of core sutures 74 – 76,81 – 83,85,94 – 98 ; (2) the tension of repairs – this is most relevant to gap formation and stiffness of repairs 19 ; (3) the core suture purchase 84,86,88,94 ; (4) the types of tendon – suture junc-tion – locking or grasping 79,88,95,98 ; (5) the diameter of suture locks in the tendons – a small-diameter lock diminishes anchor power 80,91 ; (6) the suture caliber (diameter) 82,116,117 ; (7) the mate-rial properties of suture materials 95 ; (8) the peripheral sutures 155,156 ; (9) the curvature of tendon gliding paths – the repair strength decreases as tendon curvature increases 89,90 ; and (10) above all, the holding capacity of a tendon, affected by varying degrees of trauma and posttraumatic tissue soften-ing, plays a vital role in repair strength.

The subdivisions of zone 2 by Tang are: • 2A: the area of the FDS tendon insertion • 2B: from the proximal margin of the FDS insertion to the

distal margin of the A2 pulley • 2C: the area covered by the A2 pulley • 2D: from the proximal margin of the A2 pulley to the

proximal refl ection of digital sheath.

Flexor tendon healing Flexor tendons derive nutrition from both synovial and vas-cular sources. Flexor tendons outside the synovial sheath are supplied with a segmental vascular network through the paratenon, and the vascular supply plays an important role in the nutrition of these tendons. However, the tendons within the synovial sheath are mostly deprived of a vascular network. Only limited dorsal regions around vincular insertions are vascularized. A series of experiments by Manske et al. showed that intrasynovial fl exor tendons are nourished by synovial fl uid and that nutrition through vascular supplies is insignifi cant. 47 – 50 While the general healing process of the tendon has long been recognized as having early infl amma-tory, middle collagen production, and late remodeling phases, the healing potential of the intrasynovial fl exor tendon has been a subject of intense investigations and debate over several decades. 1 – 10,52 – 61

Before the 1970s, it was widely accepted that the digital fl exor tendon lacked intrinsic healing capacity. 1 – 4 However, in subsequent decades, the intrinsic healing capacity of the tendon came to light in a series of elegant experimental studies. These experiments, by Matthews, Lundborg, Manske, Gelberman, and Mass and others, included observation of the repair process in lacerated fl exor tendons within the synovial sheath, investigation of cellular activity in the lacerated tendon within the knee joint, detection of cellular activity, and the ability to produce matrix by in vitro tendon cultures. 5 – 10,51 – 61 The work led to the well-supported conclusion that cells in the intrasynovial tendon can proliferate and participate in the healing process, making the tendon itself capable of healing without forming adhesions. This became the scientifi c basis of early postoperative tendon mobilization.

It is now agreed that intrasynovial fl exor tendons can heal through two mechanisms – intrinsic and extrinsic. Intrinsic healing takes place through the proliferation of tenocytes and production of extracellular matrix by intrinsic cells. Growth of tissues or cell seeding from outside the tendon is extrinsic healing. The tendon ’ s intrinsic healing capacity is innately weak; extrinsic healing becomes dominant when intrinsic healing capacity is disabled (such as in the case of severe trauma to the tendon or peritendinous tissues) or under con-ditions (such as postsurgical immobilization) favoring extrin-sic healing. Tendon healing exclusively through the intrinsic healing mechanism occurs only under a few experimental conditions. 7 – 9 Clinically, the lacerated tendon heals through a combination of both intrinsic and extrinsic mechanisms, whose balance depends upon the condition of the tendon and surrounding tissues. Extrinsic healing may act on the tendon-healing process either by forming adhesions or seeding the extrinsic cells without adhesions to the laceration site. On the other hand, adhesions do not necessarily consist of extrinsic cells. Tenocytes may migrate out of the laceration site


183Basic science

a tendon under linear tension is pulled without being bent, whereas a tendon under curvilinear tension is subjected to both linear pulling and bending forces. Therefore, the repair fails more easily in the fl exed fi nger under curvilinear loads. When the fi nger moves to approach full fl exion, a strongly bent tendon is particularly prone to fail ( Fig. 9.8 ) .

Annular pulleys are critical to the function of the digital fl exor tendons. The pulleys keep the tendons ’ course close to the phalanges for optimal mechanical effi ciency of tendon excursion. Lengthy loss of the sheath and pulleys causes ante-rior displacement – bowstringing – of the fl exor tendon during fi nger fl exion. In fi ngers, the A2 and A4 pulleys are most criti-cally located and functionally important. Preservation or reconstruction of the two pulleys is necessary in the absence of other pulleys or sheath. Nevertheless, given the presence of other pulleys and sheaths, the loss of any individual pulleys, including the A2 or A4 pulley, appears to result in few detrimental consequences. Both Tang 22 and Tomiano

To achieve an optimal surgical repair, the factors outlined above must be considered and incorporated into repair design. A core suture purchase of at least 0.7 – 1.0 cm is necessary to generate maximal holding power, as recommended by Tang et al. 86,93 and Cao et al. 94 A locking tendon – suture junction is generally better than a grasping junction in terms of holding power. Diameter of the suture locks must reach or exceed 2 mm, according to Xie et al. 91 Tan and Tang recommend a greater core suture purchase ( > 1.2 cm) and locking repairs for an obliquely cut tendon. 86 – 88 Barrie et al. 116 and Taras et al. 117 greatly improved repair strength by increasing suture caliber. Clinically, the caliber of suture used in adults is either 3-0 or 4-0; sutures of 2-0 or greater are too large and rigid in the hand.

Tendon – suture junctions in surgical repairs are either grasping or locking; locking junctions vary greatly ( Fig. 9.7 ) . Grasping repairs are generally weaker than locking repairs. Among locking junctions, cross-locks provide identical strength to circle-locks. 94 Exposed and embedded cross-locks create the same strength. 92 With an identical number of suture strands across the tendon, different locking junctions result in minor differences in strength. Nevertheless, repairs with cross- or circle-locks appear slightly stronger than Kessler-type repairs with Pennington locks. Pennington locks provide a looser junction than cross- or circle-locks.

Peripheral sutures serve to “ tidy up ” the approximated tendon stumps; they may add strength to repairs as well. Deep-bite peripheral sutures increase repair strength. 155 Increases in suture purchase or complex peripheral sutures, as typifi ed by the Silfverski ö ld method, 64 increase overall strength. However, most surgeons choose to insert only simple peripheral stitches. Some surgeons even do not sup-plement peripheral stitches when multistrand core sutures have been used. 25 In the presence of a strong multistrand core repair, peripheral sutures contribute little in terms of strength. In fact, to simplify repair maneuvers, multistrand core sutures (with or without a few peripheral sutures) may be suffi cient.

In addition to surgical factors, tendon curvature affects strength as well. Surgical repair in a tendon under a curvilin-ear load is weaker than that under a linear load; the repair strength decreases as the curvature increases. 89,90 Mechanically,

Fig. 9.6 Factors affecting the surgical repair strength of the tendon.

Strands: 2, 4, 6 or 8

Suture purchase length

Tension of repair

Suture caliber

Locking or grasping anchor

A Core suture

Holding capacity of tendon

tissue (Degrees of trauma

and softening of tendon)E

Number of runs

Suture purchase

Caliber and tension

B Peripheral suture

Material properties

of suturesC

Curvature of the

gliding pathD

Repair strength

Factors affecting surgical repair strength

Fig. 9.7 Different tendon – suture junctions in tendon repairs: locking and grasping junctions.

Cross-lock (embeded)

Cross-lock (exposed)

Circle-lock

Loop-lock

Pennington-lock

Grasp (nonlock)



Flexor tendons in the digits glide in a fairly resistance-free synovial environment. Resistance to tendon motion is increased when the tendons are injured and repaired. The following create resistance to tendon gliding: (1) rough tendon gliding surface; (2) biological reactions of the wound, e.g., subcutaneous and tendon edema; (3) friction caused by exposure of suture materials; (4) increases in tendon bulkiness due to placement of sutures; (5) tight closure of sheath or pulleys that narrows the tendon gliding tunnel; (6) tendon-catching at pulley or sheath edges; (7) postsurgical extensor tethering and joint stiffness that burden the move-ment of the fl exor tendon; and (8) adhesions that restrict tendon gliding.

Following trauma and surgery, tendons undergo infl am-mation, healing, and edema. The volume of the tendons is increased, which increases the resistance within the narrow sheath tunnel. Subcutaneous edema outside the sheath also impedes tendon motion. These factors affecting the resistance to tendon gliding should be considered in deciding how rigor-ous the postoperative motion program should be. The safety margin can be enhanced by a strong surgical tendon repair or appropriately decompressing the tendon to avoid repair ruptures.

Biological healing strength is a central issue underlying all tendon repairs. Urbaniak et al. , 76 Kubota et al. , 77 Aoki et al. 78 and Boyer et al. 114 have characterized the strengths of the healing fl exor tendon using animal models. They found that strength either remained consistent or actually decreased somewhat over the initial few weeks after surgery. 76 – 78 Decreases in strength, typically those in the second postsurgi-cal week, are thought to be caused by softening of the tendon stumps, which lower the sutures ’ holding power. Our inves-tigations using a chicken model indicated that the strength of a healing tendon is steady during the initial 4 weeks, followed by a substantial increase (greater than threefold) in the fi fth and sixth weeks; thereafter, the tendon heals strongly and is diffi cult to disrupt. The fi fth and sixth weeks after surgery appear crucial to regaining strength. Accelerating healing, aiming to move this critical “ strength gain ” period to earlier weeks, is a current focus of research into molecular modula-tion of tendon healing.

Diagnosis/patient presentation Flexor tendon injuries are open in most cases, resulting from a sharp cut or a crush, but they can also present as closed injuries. Open injuries due to extensive trauma are frequently associated with neurovascular defi cits. Closed injuries often relate to forced extension during active fl exion of the fi nger. Flexor tendon rupture can also occur as a result of chronic attrition in rheumatoid disease, Kienbock disease, scaphoid nonunion, or hamate or distal radius fracture.

Careful attention to the patient ’ s history and the mecha-nism of injury can alert the surgeon to the extent of the tendon trauma and associated injuries. The natural resting posture of the wounded digits is important for evaluation. Complete lacerations of both FDP and FDS tendons are easily diagnosed when the affected fi ngers are seen in a relatively extended position with loss of active fi nger fl exion at PIP and DIP joints. If the patient can actively fl ex the DIP joint while the

et al. 111,112 have shown that incision of the A2 pulley up to one-half or two-thirds of its length or of the entire A4 pulley results in no tendon bowstringing and little loss of digital fl exion. In in vivo settings, incision of the A2 pulley decreases resistance to tendon motion and lessens the chance of repair failure. 109,110 Loss of the A3 pulley alone has few consequences as well, but a lengthy sheath cut adjacent to the A3 pulley, containing C1 or C2, causes tendon bowstringing. 107 Therefore, signifi cant loss of sheath should be avoided to maintain tendon function; however, loss of a small portion ( < 2 cm in length) of the sheath and pulley, even including a part of the most critically located A2 pulley, has no substantial mechani-cal consequence.

Fig. 9.8 The forces acting on the tendon are different when the tendon is subjected to linear pulling (A) or curvilinear tension (B and C). (A) The tendon subjected to linear pulling is loaded by only a linear pulling force. (B and C) The tendon subjected to a curvilinear tension is loaded by both linear and bending forces. The repaired tendon fails more easily while being linearly pulled and bent. From B to C, as the curvature of the gliding path increases, the bending force on the tendon is increased (F2 > F1). Under greater gliding curvature, the tendon fails with a smaller linear pulling force. From B to C, as the fi nger fl exes progressively, the tendon fails with an increasingly smaller linear tension. (C) The tendon is particularly prone to fail when the fi nger approaches full fl exion. The tendon is easier to disrupt in (C) when gliding over joints (1 ’ and 2 ’ ) with greater curvature than in (B) with smaller curvature.

F F’

2

2’1

1’

F1

F2

F’ F F’

A

CB


185Treatment/surgical techniques

Radiographs should always be taken. Associated fractures are not infrequent and require treatment. Computed tomography (CT) scan or magnetic resonance imaging (MRI) is not usually necessary to diagnose open tendon inju-ries. However, for diagnosis of closed tendon ruptures or suspected ruptures of the primary end-to-end surgical repair, these tools are of particular values. CT or MRI should be prescribed for the cases suspicious of closed tendon ruptures. Ultrasonographic examination may also reveal rupture of the tendons.

Treatment/surgical techniques

Primary and delayed primary repairs Whenever possible, acutely lacerated fl exor tendons in the hand and forearm should be treated primarily or at the delayed primary stage. Primary tendon repair is the end-to-end repair performed immediately after wound cleaning and debridement, usually within 24 hours of trauma. Delayed primary repair is defi ned as repair performed within 3 or even 4 weeks after tendon lacerations. No clinical investigations actually validated the best time for primary repair. The ideal situation is that of a patient with digital fl exor tendon lacera-tions brought into the clinic soon after injury; surgery begins within a few hours, and an experienced surgeon is readily available. The tendon injured in critical areas (such as zone 2)

Fig. 9.9 Examination of fl exor digitorum profundus (FDP) tendon continuity and function. When the proximal interphalangeal joint fl exion is blocked, fl exion of the distal interphalangeal joint indicates continuity and function of the FDP tendon.

Fig. 9.10 Examination of fl exor digitorum superfi cialis (FDS) tendon continuity and function. If the patient is unable to fl ex the proximal interphalangeal joint of the examined fi nger while fl exion of the other fi ngers is blocked, this indicates loss of function of the FDS tendon. Complete fl exion of the proximal interphalangeal joint indicates function and continuity of the FDS tendon.

motion of the PIP joint is blocked, no injuries or only partial injuries to the FDP tendon can be diagnosed ( Fig. 9.9 ) . To assess the continuity of the FDS tendon, the adjacent fi ngers are held in full extension by the examiner. If the patient cannot actively fl ex the PIP joint, the FDS tendon is completely severed ( Fig. 9.10 ) . Variations in the FDS tendons in the little fi nger are frequent. The FDS in 30 – 35% of the little fi ngers is connected with the FDS in the ring or middle fi ngers. Some little fi ngers (10 – 15%) are missing an FDS tendon. These patients have limited or no PIP fl exion of the little fi nger during testing. Weakness during resisted fi nger fl exion indicates a possible partial tendon cut. To test the FPL tendon, the thumb MCP joint is stabilized in a neutral position. The patient is asked to fl ex the IP joint. Loss of active fl exion at the joint indicates complete severance of the FPL tendon.

Nerve and vascular function should be assessed routinely because accompanying injuries in the neurovascular bundles in one or both sides of the fi ngers or median and ulnar nerves at the carpal tunnel or distal forearm are common. Loss of sensation in the fi nger pulps or loss of function of intrinsic muscles in the hand is indicative of such accompanying inju-ries; treatment of neurovascular injuries must be included when planning surgical strategies. If fi ngers or hands are found to be hypovascular or avascular due to vascular lacera-tions, vascular anastomosis should be a surgical emergency. Otherwise, after wound debridement, either the lacerated fl exor tendons can be repaired (when experienced surgeons are readily available) or the skin can be closed to allow for delayed primary repairs within days by experienced surgeons.



Surgical techniques Brachial plexus block is usually suffi cient; general anesthesia can also be used when associated injuries are severe. The hand and arm are scrubbed and draped. A tourniquet is placed on the upper arm. The wounds should be thoroughly debrided, devitalized tissues excised, and the wounds washed with antibiotic solution. The position of the fi ngers or hand is deter-mined by levels of cuts in the tendons in relation to their superfi cial tissues. The hand is usually held by an assistant, so that it can be adjusted during surgery. Loupe magnifi cation is advised for surgery. The tendons are exposed through zigzag skin incisions on the volar side of the fi ngers, e.g., Bruner ’ s incision, or a lateral incision. When the wounds are in the palm or forearm, incision by extending the wound opening is often necessary ( Fig. 9.12 ) .

Zone 1 injuries

In this area, only the FDP tendon is located. When the tendon laceration is in the distal part of this zone (zone 1A and 1B), because the vincula connect to the proximal tendon to prevent retraction, both the proximal and distal ends can be easily found not far from the skin wound. When cut in zone 1C, the tendon may retract more proximally. For zone 1A injuries, the distal stump is usually too short for direct end-to-end repair. The proximal tendon end can be sutured with Bunnell or modifi ed Becker suture with 3-0 polypropylene, and an oste-operiosteal fl ap is raised at the base of the distal phalanx ( Fig. 9.13 ) . The suture is led through an oblique drill hole, brought out through the nail, and tied over a button above the nail. To avoid passing the suture through the nail, the proximal tendons can be sutured to a fi sh-mouth opening in the distal tendon stump using reinforced suture repairs or minianchors ( Fig. 9.13 ). 156,157 Another method is to drill a transverse hole through the distal phalanx. After the tendon stump is sutured, the suture is led through the hole and tied to the other end, through an open approach or percutaneously. 158,159 Injuries in zones 1B and 1C usually create tendon stumps of suffi cient length for a direct surgical repair, which can be treated by

should not be repaired by an inexperienced surgeon. Rather, tendon repair can be delayed until an experienced surgeon is available. My preferred period of deliberate delay is 4 – 7 days, when the risk of infection can be properly addressed and edema has reduced substantially. Delay of the repair beyond 3 – 4 weeks may cause myostatic shortening of the muscle – tendon unit; for these late cases, lengthening the tendon within the muscles in the forearm can ease the tension ( Fig. 9.11 ) . 157

Rupture of the repaired fl exor tendons after surgery can be re-repaired if the rupture occurs within a few weeks up to a month after surgery; secondary tendon grafts may be the only choice for ruptured cases in the presence of obvious retraction of the tendon end or extensive scarring in the intact FDS tendon when the FDP tendon ruptures.

Indications and contraindications Primary or delayed primary end-to-end tendon repairs are mainly indicated in clean-cut tendon injuries with limited damage to peritendinous tissues. Neurovascular injury is not a contraindication for primary repairs. Loss of soft-tissue cov-erage over the tendon and the presence of fractures are bor-derline indications. Local defects in skin and subcutaneous tissues can be covered by fl ap transfer. A simple fracture limited to the phalangeal or metacarpal shaft can be securely fi xed with screws or miniplates, and then tendons can be repaired. However, serious crush injuries, severe wound con-tamination, loss of extensive soft tissues, or extensive destruc-tion of pulleys and tendon structures are contraindications for primary tendon repairs. Fractures involving multiple bones, particularly at different levels or not yielding stable internal fi xation, are contraindications for primary tendon repairs ( Box 9.2 ).

Fig. 9.11 A decision-making fl ow chart of primary and delayed primary fl exor tendon repairs.

In making a decision of primary repair, consider:

• General conditions of the patient

• Availability of an experienced surgeon

Perform delayed primary repair after

wound infection controlled, edema

subsided and an experienced

surgeon available

Delayed repair with

difficulty, may need to

release muscle tension

Primary

repair

< 1day

Delayed primary repair

3 weeks 1 month

Tendon

trauma

Day 0

Ideal within 2–3 weeks, possible at 1 month or even later

Box 9.2 Primary fl exor tendon repairs

Indications • Clean-cut tendon injuries • Tendon cut with limited peritendinous damage, no defects in

soft-tissue coverage • Regional loss of soft-tissue coverage or fractures of phalangeal

shafts are borderline indications • Within several days or at most 3 or 4 weeks after tendon

laceration

Contraindications • Severe wound contamination • Bony injuries involving joint components or extensive soft-tissue

loss • Destruction of a series of annular pulleys and lengthy tendon

defects • Experienced surgeons are not available



requirements of a tendon repair are: (1) suffi cient strength; (2) smooth tendon gliding surface, with minimal suture (and knot) exposure; (3) no gapping of the repair site under tension; and (4) easy to perform.

Surgical suture techniques vary among surgeons. Some core suture methods are shown in Figure 9.14 . The modifi ed Kessler and cruciate techniques are further shown in Figure 9.15 . The Bunnell method is no longer popular for end-to-end repair. The two-strand modifi ed Kessler method and Tsuge method are among the most widely used over the past 40 years. In the last 20 years, a number of multistrand repair techniques have emerged, 14 – 19,65 – 69 , including four-strand repairs such as cruciate, modifi ed Savage, Strickland, and double Kessler; six-strand repairs such as Savage, Lim-Tsai, Tang, M-Tang; and eight-strand Winters – Gelberman methods. I prefer multistrand methods, typically four- or six-strand repair methods when repairing lacerated FDP tendons in zone 2.

In my practice, I have used the double Tsuge method or six-strand methods in the past 20 years. In the last decade, my colleagues and I have started to use modifi cations of the origi-nal methods to repair tendons using fewer looped lines and knots, but maintaining suture strands and repair strength across the repair site identical to those of the original methods ( Fig. 9.16 ) . These methods are relatively easy and surgical repair strength is very reliable ( Figs 9.17 – 9.23 ) .

Using a needle carrying two separate suture lines, or with remaining pieces of the looped suture line after making the repairs described above, we can make a variety of four-strand Kessler-type repairs by introducing double sutures through one needle passage ( Fig. 9.24 ) . These techniques are used in my clinic as well as by my colleagues. We use these methods when repairing fl atter tendons in some instances, such as the FDS cut proximal to bifurcation. 72

Epitendinous stitches smooth the approximation of the tendon ends and resist gapping during tendon movement. Simple running peripheral, locking running peripheral, cross-stitch peripheral, and Halsted horizontal mattress sutures are among those most often used, with the fi rst two more popular ( Fig. 9.25 ) . Some surgeons prefer “ deep-bite ” peripheral stitches to add strength to repairs. 155 An epitendinous suture is usually added after the completion of core sutures, but it can also be added fi rst. 156 Peripheral stitches can be unneces-sary given a strong multistrand core suture. 25 Clinically, peripheral repairs vary from complex stitches to none. My preference is to use a simple running peripheral suture with 6-0 nylon after completion of a four- or six-strand core suture repair.

Technically, to make an optimal surgical repair, the length of core suture purchase in each tendon end should be at least 7 mm to 1.0 cm. Surgical repair strength decreases as the length of the suture purchase decreases ( Fig. 9.26 ) . In addition, certain tension across repair site is benefi cial to resist gapping. In my experience, a certain tension (resulting in about 10% shortening of the encompassed tendon, when the proximal tendon is temporarily fi xed during surgery) appears benefi -cial, because a small amount of baseline tension in the repair would counteract the tension of the locomotor system during resting or active motion. When locking the suture junction in the tendon is incorporated to the core sutures, the locking circles of the suture in the tendon should be of a suffi cient diameter (approximately 2 mm). After completing the repair,

methods similar to treatment in zone 2. Core tendon sutures, such as the modifi ed Kessler, cruciate, modifi ed Becker, or double Kessler repair, can be placed to the proximal end through a window opening in the proximal sheath. The proxi-mal end is brought underneath the intact sheath between the wound and the proximal opening to approximate the distal end.

Zone 2 injuries

Tendon injuries in this area are often exposed through a Bruner skin incision and a window opening in the synovial sheath, a release, or local excision of a short part of the annular pulleys. If the tendon ends have not retracted far proximally, fl exion of the MCP or PIP joint can effectively bring the proxi-mal end into sight. Sometimes the proximal tendon end is found retracted even to the middle of the palm. In this instance, an additional incision is made in the palm to expose the tendons, and the proximal tendon end is pulled distally within the synovial sheath by loosely suturing the tendon to a catheter. The end is brought out of the distal opening in the sheath to approximate the distal end. While the fi nger is held in slight fl exion, a 25-gauge needle is then inserted at the base of the fi nger through the proximal tendon to hold the tendon temporarily and to release the tension at the surgical suture site.

During surgery, tendons should be handled atraumatically and ragged tendon tissue at the cut ends should be removed with a scalpel. Stronger suture materials are preferred: 3-0 or 4-0 sutures (nylon or coated nylon) are common choices. Basic

Fig. 9.12 Skin incisions utilized to approach the tendons in the digits and palm.

Video

1



Fig. 9.13 Methods of making a tendon-to-bone junction in zone 1. (A) A conventional method of anchoring the fl exor digitorum profundus (FDP) tendon to the bone by pull-out sutures through the nail tied over a button. Alternative ways to anchor the distal tendon stump to the bone by: (B) directly suturing the stump to residual FDP tendon, (C) looping the tendon through the bone, (D) pull-out suture over the fi ngertip, (E) minianchors, and (F) looping the sutures through a transverse hole in the bone (F).

A B C

D E F

Mini anchors

Sutures

FDP tendon

Button



Fig. 9.14 Summary of methods used to make core sutures in fl exor tendon repairs.

BA

DC

FE

HG

JI

Bunnell

Tsuge

Cruciate

4-strand Savage

Tang or 6-strand Tsuge

Modified Kessler

Double Kessler

Indiana or 4-strand Strickland

Modified Becker

Modified Savage

Fig. 9.15 Two common techniques in fl exor tendon repairs: (A) modifi ed Kessler method; and (B) cruciate method.

A

B

i ii iii

i ii iii



Fig. 9.16 The technique for making a six-strand M-Tang tendon repair. Two separate looped sutures are used to make an M-shaped repair within the tendon. (A – C) A U-shaped four-strand repair is completed, which can be used alone for tendon repair. (D and E) An additional looped repair is added at the center, to complete the six-strand repair. In tendon cross-sections, three suture groups are placed at points of a triangle to avoid interference to the dorsal center of the tendon where the vascular networks converge. The dorsolateral sutures may act as tension bands to resist gapping of the tendon.

A

B

C

D

E

Fig. 9.17 A case with complete laceration of the fl exor digitorum profundus tendon and partial fl exor digitorum superfi cialis laceration in zone 2B. The surgery was performed 10 days after injury. The wound was exposed through a Bruner incision, and the distal half of the A2 pulley was incised through the volar midline. A needle is inserted transversely through the sheath and proximal tendon to temporarily fi x the proximal tendon to ease tension during repair.

Fig. 9.18 The lacerated fl exor digitorum profundus tendon was found through a separate incision in the palm and led underneath the sheath and pulleys to the operation fi eld distal to the A2 pulley, to approximate the distal stump.

the cut tendon ends should align well, and no gapping between the tendon ends should be observed ( Box 9.3 ).

In the past 10 years, novel repair concepts have emerged and novel materials have been used. For example, of potential clinical merit are techniques involving a single passage of the needle carrying double or even triple strands into the tendon 69,160 – 162 ; FiberWire also offers a strong suture material for tendon repairs. 95,163 These methods are effective in enhanc-ing strength with a minimal suture passage in the tendon.

Closure of the synovial sheath is no longer considered essential for tendon repairs after hot debate in the 1980s and

Box 9.3 Recommended surgical tendon repairs

• More than two strands as the core repair – four or six strands are recommended

• Certain tension across the repair site – 10% shortening of tendon segment after repair

• Core suture purchase: 7 – 10 cm • Locking tendon – suture junctions in core suture • Diameter of the locks: 2 mm or over • Suture calibers: 3-0 or 4-0 for core suture • A variety of nylon sutures, or a FiberWire suture • A simple running or locking peripheral suture • No peripheral suture if core repair is very strong • Avoid extensive exposure of sutures over the tendon surface



Fig. 9.19 Completion of inserting a four-strand repair using one looped suture line. Fig. 9.20 Completion of the six-strand M-Tang repair.

Fig. 9.21 Addition of a simple running peripheral repair. Fig. 9.22 Follow-up at 10 months after surgery: full fl exion of the repaired fi nger, without tendon bowstringing.

early 1990s. 164 – 171 Closure may be attempted in clean-cut injury when sheath defects or abrasions are absent. It is now agreed that avoiding compression or constriction to the ede-matous tendons by the sheath or annular pulleys after surgery is very important to tendon healing. With major pulleys and a majority of the sheath intact, leaving a part of the synovial sheath open has no signifi cant adverse effect on tendon function and healing. On the other hand, incision of one single annular pulley (A1, A3, or A4) or a critical part (up to two-thirds of its length) of the A2 pulley does not signifi cantly affect tendon gliding when all other pulleys or the synovial sheath are intact. Such a release can in fact be benefi cial to tendon healing and gliding: as healing responses and adhesions arise, it releases constrictions on edematous tendons.

Clinically, the A4 or A2 pulley sometimes constitutes an obstacle for the edematous tendon to glide through, which may cause repair rupture during tendon motion exercise. The perceived need for complete preservation of the A4 and A2

pulleys during primary repairs is “ borrowed ” from the surgery pertaining to secondary tendon reconstructions, and does not hold true when the tendons are cut through a single wound and other sheaths or pulleys are intact. Contrary to the practice of 10 or 20 years ago, releasing the A4 pulley entirely and releasing a part of the A2 has become accepted clinical practice in recent years. 19,23,150,172 In the author ’ s clinic, when the repaired FDP tendons are found tightly entrapped by the A4 pulley after testing during surgery, we completely release the A4 pulley ( Figs 9.27 and 9.28 ) . A part of the A2 pulley, either proximal or distal (about one-half to two-thirds the length of the A2 pulley) ( Figs 9.17 – 9.21 ), is cut when both the FDS and FDP tendons are repaired in the area of or distal to the A2 pulley. When the repair is considerably delayed (3 weeks after injury), the A2 pulley usually collapses or is even embedded within scars. I excise a portion of the A2 pulley to shorten this pulley ( Figs 9.29 – 9.33 ) .

The release usually needs to include a part of the adjacent synovial sheath. The total length of the sheath pulley release

Video

1



Fig. 9.24 Other designs of four-strand repairs by two separate strands or one looped suture line led by a single needle. These repairs, with fewer needle passages within the tendon, have strengths identical to the double Kessler method. (A) A four-strand repair with knots on two lateral sides of the tendon. (B) A U-shaped four-strand repair made with one looped suture line. (C and D) Two separate strands carried by a single needle to make a four-strand cross-lock repair or a four-strand Kessler repair (knots on one side of the tendon).

A

B

C

D

i

ii

iii

Fig. 9.25 Two simple common methods of peripheral suture. (A) Simple running peripheral suture. (B) Running locking peripheral suture.

B

A Simple running peripheral suture

Locking running peripheral suture

Fig. 9.23 Full extension of the repaired fi nger.



Fig. 9.26 Two bad repairs decrease the strength: (A) a repair with insuffi cient core suture purchase and (B) a loose repair. Suffi cient core suture purchase and a certain pretension favor resisting gapping and decrease the chance of repair failure during tendon motion after surgery.

B

A

Gapping / disruption

Solution : Maintain core suture purchase

>7-10 mm

< 4 mm

Tension

Gapping

Loose repair

Solution : Repair with a certain

light tension

Tension

Fig. 9.27 The constricting A4 pulley sometimes presents an obstacle for the passage of the fl exor digitorum profundus tendon.

Fig. 9.28 The A4 pulley and a part of its adjacent sheath were vented to allow tendon passage. Other parts of the sheath were not violated. In this case, the fl exor digitorum profundus tendon was repaired with a six-strand original Tang repair using three groups of looped sutures.

Fig. 9.29 A case of ruptured primary repair referred to the author. We performed direct repair of the ruptured fl exor digitorum profundus tendon 3 weeks after the fi rst tendon repair. The fl exor tendons and A2 pulleys were found embedded within scars.

is about 2 cm in adults, which amply decompresses tendon gliding, but does not lead to functional disturbance. The areas of the release are shown in Figure 9.34 .

Over the years, release of the pulleys has been achieved differently: (1) incision of the entire or a critical part of the major pulley 19,22,23,150 ; (2) excision of a part of the major pulley 19 ;

(3) omega, Z, or V-Y pulley plasty 173 – 175 ; and (4) sheath enlarge-ment plasty. 176,177 My current pulley release is a simple proce-dure: incising the A4 or a portion of the A2 pulley, or partially excising the A2 pulley, while obviating complicated sheath- or pulley-plasty surgeries.

Whether or how to repair the FDS tendon when both fl exor tendons are injured is a subject of diverse opinions, particu-larly in the areas covered by the A2 pulley or distal to it. A few reports have discussed it specifi cally. 21,178,179 Repair of one slip of the FDS is also feasible. 100,108 In the area of the A2 pulley (zone 2C), I prefer to excise the FDS locally in cases with severe peritendinous injuries, when the tendons appear ede-matous, and in cases with delayed primary repairs. In per-forming the delayed repair, I fi nd it almost impossible to repair the FDS tendon in zone 2C, because some degree of

Video

1



or enlarge the sheath (when both tendons are repaired prima-rily or only the FDP tendon is repaired at the delayed stage). The underlying idea is that the fi bro-osseous digital fl exor sheath tunnel is comparable to a tight fascia compartment of extremities; the edematous and healing tendons are easily compromised. Release of compression of the tendon to avoid overloading it during motion can be more vital to the success of treatment than providing it with suffi cient surgical strength.

Surgical options currently advised to deal with tendons and pulleys in the most complex areas of fi nger fl exor tendons are summarized in Table 9.1 .

collapse or narrowing of the A2 pulley is inevitable, and the tendons are often edematous. In zone 2B, where the FDS tendon is bifurcated into two slips, I use two Tsuge repairs separately in each tendon slip; when the laceration is close to the insertion, I anchor the tendon slips to the phalanx. Treatment of the FDS tendon in zone 2D is straightforward, similar to the FDP tendon, except that the FDS is fl atter and four or fewer strands are used.

In deciding surgical options relating to both the FDS and the pulleys, I generally seek to decrease the gliding contents appropriately (by not repairing or excising the FDS tendon)

Fig. 9.30 The A2 pulley was partially excised and the intact part of the A2 pulley was released from the scar. The ragged tendon ends were trimmed to fresh tendon surfaces.

Fig. 9.31 The proximal tendon stump was passed underneath the preserved portion of the A2 pulley. The tendon was repaired with the six-strand M-Tang technique.

Fig. 9.32 Follow-up 6 months after surgery. Full fl exion of the fi ngers was achieved, without tendon bowstinging during active fi nger fl exion.

Fig. 9.33 Full extension of the fi nger, without extension defi cits of the fi nger joints.



Fig. 9.34 Drawings depicting the length and areas of release of the pulley – sheath complex to decompress the repaired tendons, without bowstringing or loss of tendon function. (A) Release of the entire A4 pulley when the fl exor digitorum profundus tendon has been cut around the A4 pulley and the tendon cannot pass easily beneath this pulley during surgery. (B) Release of a part of the sheath distal to the A2 pulley and the distal half of the A2 pulley, when the tendons are cut slightly distal to the A2 pulley. (C) Release of a short part of the sheath distal to the A2 pulley and the distal two-thirds of the A2 pulley when repairing tendons cut at the edge of, or in the distal part of, the A2 pulley. (D) Release of the proximal two-thirds of the A2 pulley when repairing a cut in the middle, or proximal part of, the A2 pulley.

A1A2C1A3C2A4C3A5

Tendon laceration

A1A2C1A3C2A4C3A5

Sheath-pulley release

Tendon laceration Sheath-pulley release



A

B

C

D

Table 9.1 Summary of mechanical basis and surgical options advised to deal with the fl exor digitorum superfi cialis (FDS) tendon and pulleys in zone 2 of the fi nger

Area of FDS Insertion Distal to A2 pulley Beneath A2 pulley Proximal to A2 pulleyInvestigations (2A) (2B) (2C) (2D)

Anatomic

FDS tendon Insertion 2 slips, dorsal to FDP, with vincula

Bifurcation One single band, fl attened palmar to FDP

Pulleys A4, C2, narrow A3, C1 A2, narrow A1, PA

Biomechanical

FDS tendon No gliding Not constricting FDP Constricting FDP, as a moving and second “ pulley ”

Little constriction

Pulleys A4 release is feasible 112 May incise one pulley 107 Partial release is feasible 22,111,112

Clinical options

FDS tendon Repair 174,214 Resection or do not repair 21,23,150 Resect one slip 101

Repair both tendons when possible

Pulleys A4 venting 19,23,172 Partial release 19,23,150,172 Pulley shortening or plasty 100,175

FDP, fl exor digitorum profundus; PA, palmar aponeurosis.



Fig. 9.35 A 9-year-old boy with a complete fl exor pollicis longus (FPL) tendon cut. (A) The retracted proximal tendon end was found and temporarily fi xed with a needle to accommodate tendon repair. (B) The FPL tendon was repaired with the six-strand M-Tang technique.

A B

Zone 3, 4, and 5 injuries

The repair techniques for injured fl exor tendons proximal to zone 2 are almost identical to those used in zone 2. These zones have a better prognosis because of richer vascularity around the tendon and lack of constricting pulleys over the tendons. Adhesions in these areas are less likely to impede tendon motion. Zone 4 tendon injuries are frequently accom-panied by lacerations in the median nerve and arteries. The transverse carpal ligament may be partly opened to facilitate repairs and left partly open after tendon repairs. In most cases zone 5 tendon injuries are presented as multiple tendon lac-erations with neurovascular injury. A wrist with transection of a majority of tendons, vessels, and nerves (at least 10 out of 15 of these structures, excluding palmaris longus) is called a “ spaghetti ” wrist. 179 – 183 A “ spaghetti ” wrist was reported to have an adverse effect on the recovery of the independent FDS action but not on the recovery of the digital range of motion. 183 In zone 5, repair of the FDS tendon is preferred, and early postoperative tendon motion is advised, 183 – 185 This favors independent movement of the superfi cialis.

FPL injuries

Repair of the injured FPL tendons in the thumb usually follows the same principles and methods of repair of the FDP tendon in fi ngers. Multistrand repairs are advised, and one or two pulleys can be vented to free tendon motion. Reports have shown that conventional two-strand repairs have a risk of rupture as high as 17%. 25,172 In a recent report from David Elliot ’ s hand center, Giesen et al. 25 reported no ruptures and good function after using a six-strand Tang method without peripheral sutures in repairing 50 FPL tendons. In this case series, which reported the best outcomes of FPL tendon repairs thus far, the oblique pulley was vented and the sheath was not closed. The authors found that this six-strand repair was safe for early active mobilization and easier to perform than Kessler core sutures and elaborate Silfverski ö ld sutures.

In repairing the FPL tendon, the proximal cut end of the tendon frequently retracts into the thenar muscles. This end can be retrieved with the techniques described for retracted

FDS and FDP tendons ( Figs 9.35 – 9.37 ) . If the proximal stump of the FPL tendon has retracted proximal to the thenar muscles, a separate incision in the forearm is required to locate the stump. The FPL stump usually lies deep to the FCR tendon and the radial artery.

Injuries in children

Flexor tendon repairs in children have a better prognosis than those in adults. 186 – 190 As children may be less compliant with instructions to limit movement, the repaired digits are usually immobilized for 3 – 3.5 weeks after surgery. Either a two-strand or a four-strand repair can be used. In practice, many sur-geons use a two-strand repair and achieve good return of function. The outcomes appear unaffected by whether a

Fig. 9.36 Follow-up 8 months after surgery. Full fl exion of the repaired thumb.


197Postoperative care

commonly in the ring fi nger. Closed tendon ruptures at the wrist can be associated with fractures in carpal bones. 203 Flexor pulleys are prone to sprains and ruptures during climbing. Rupture of the pulleys occurs in up to 20% of climbers. 204 The A2 pulley of the ring fi nger is the most often injured. Closed pulley ruptures are treated conservatively or by surgical reconstruction.

Leddy and Packer 200 classifi ed close tendon ruptures into the following types: I. The FDP tendon is avulsed from the phalanx and

retracts into the palm. The vincula of the FDP tendon are disrupted. There is no active fl exion of the DIP joint. A tender mass is present in the palm. The tendon should be reinserted within 7 – 10 days because the sheath collapse may prevent advancing the tendon distally during surgery. Muscle contracture may also prevent tendon advancement.

II. The FDP tendon retracts to the level of the PIP joint. This is the most common type. The sheath is not compromised, and muscle contracture does not develop easily. Repair may be attempted 1 month after injury.

III. A large bone fragment is attached to the FDP tendon. This bone fragment frequently prevents the tendon from retracting proximal to the A4 pulley. Bony fi xation using a K-wire or a screw usually suffi ces.

IV. The FDP tendon avulses from the bony fragment. This type was added by Smith. 200 The avulsed tendon retracts beyond the middle phalanx and even into the palm. In treating type IV injuries, the bony fragment is attached into the distal phalanx fi rst; then the avulsed tendon is advanced. Postoperatively, the DIP joint is immobilized for 4 – 5 weeks, or a gentle motion regime is prescribed.

Early recognition of closed tendon ruptures is of paramount importance. In cases where there is late diagnosis, primary repair is diffi cult or even impossible. Chronic cases require free tendon grafting.

Postoperative care With the exception of a few instances – such as tendon repairs in children, adults who are unable to follow through the pro-tocol, or associated with fractures or particular health condi-tions – motion of repaired tendons should be initiated from the early postsurgical period. From the 1970s to the 1990s, Kleinert and Duran – Houser protocols were most popular. The protocols have evolved and the methods presently used in many clinics are combined active – passive regimes.

The modifi ed Kleinert method In the 1960s, Kleinert and associates introduced a controlled active extension – passive fl exion motion protocol. 205 The wrist is palmarly fl exed with a dorsal protective splint with 30 – 40 ° wrist fl exion, 50 – 70 ° MCP joint fl exion, and the IP joints are allowed full extension. Rubber bands are secured to the volar forearm and attached to the tip of the injured fi nger ( Fig. 9.38 ) . Patients are allowed to extend the fi ngers actively and the fi ngers are brought back to fl exion passively by the tensed

two- or four-strand is used or whether the tendon is moved or immobilized early after surgery. 188,189 Navali and Rouhani 188 reported that both a two-strand and four-strand repair achieved good functional return, with no difference in range of active digital motion between the two methods. Elhassan et al. 189 reported that early postoperative motion and immobi-lization did not affect outcomes in children aged 2 – 14 years with injuries in zones 1 and 2.

Partial tendon lacerations

Laceration through less than 60% of the diameter of the tendon does not necessitate a repair by core sutures. An increased risk of triggering, entrapment, or ruptures is associated with partial laceration over 60%. 191 – 195 For lacera-tions less than 60%, the tendon wound can be trimmed to lessen the chance of entrapment by pulley edges and friction against the sheath. Alternatively, the cut portion of the tendon can be repaired with epitendinous stitches to smooth the tendon surface and to strengthen the tendon. Laceration of 60 – 80% requires at least an epitendinous repair 196 – 199 and is better repaired using a two-strand core suture through the cut portion. Laceration of 80 – 90% is treated identically to a com-plete laceration.

Closed rupture of the fl exor tendons and pulleys

Traumatic FDP tendon avulsion from the tendon – bone junction accounts for a major portion of closed rupture cases. 200 – 203 The injury mechanism is hyperextension of the DIP joint, which subjects the FDP tendon to excessive load. The tendon disrupts at its insertion to the distal phalanx. Athletic injuries can lead to this type of injury. In football, wrestling, or rugby, when one player grabs another ’ s jersey, a fi nger may be caught and pulled, resulting in disruption of fl exor tendons. This injury ( “ jersey fi nger ” ) is seen most

Fig. 9.37 Full extension of the thumb.



are allowed full extension ( Fig. 9.38 ). Within the fi rst 4.5 weeks, the patients perform 10 passive DIP joint extensions with PIP and MCP joint fl exions, and 10 passive PIP joint extensions with MCP and DIP joint fl exions hourly within the splint ( Fig. 9.38 ). This protocol decreased the frequency of PIP joint contracture seen with Kleinert ’ s rubber band traction.

Strickland and Gettle modifi ed this protocol by adopting a Duran-like protocol for a four-strand tendon repair, 209 later known as the “ Indianapolis method. ” This protocol consists of two splints, the dorsal-blocking splint (used during periods of rest and passive motion, with the wrist at 20 – 30 ° of fl exion, MCP joints in 50 ° of fl exion, and IP joints in neutral position) and a tenodesis splint (used when performing place and hold exercise). The latter hinged wrist splint permits the wrist posi-tion to be varied between fl exion and extension. With the tenodesis splint, the patient passively fl exes the digits while actively extending the wrist. The patients passively push their fi ngers into a passive composite fi st with the wrist extended

rubber bands. This method was popularized in the late 1970s and 1980s. Later, rubber band traction was found to lead to fl exion contractures of the fi nger. The original method was largely replaced by its modifi cation with a palmar bar at the level of the MCP joint as a pulley for the rubber bands to create greater fl exion of both the PIP and DIP joints ( Fig. 9.38 ). 206,207 In addition, the elastic band is detached at night and the fi ngers are strapped into extension within the splint to minimize the risk of fl exion contractures of the fi ngers. In recent years, some surgeons have advised to abandon rubber band traction.

Duran – Houser method This is a controlled passive fi nger fl exion protocol without traction of rubber bands; it was introduced by Duran and Houser in the 1970s. 208 A dorsal splint is applied with the wrist in 20 ° fl exion, the MCP joint in 50 ° fl exion, and the IP joints

Fig. 9.38 (A) Original and (B) modifi ed Kleinert passive extension protocols, and (C) Duran passive tendon motion protocols. A volar bar is added to increase fl exion of the interphalangeal joints in the modifi ed Kleinert protocol.

B

A

C Duran and Houser passive motion rigeme

Nail hook Nylon fishing line

Rubber band

Rubber band

Pulley

Modified Kleinert regime (Chow)

Original Kleinert rigeme


199Outcomes, prognosis, and complications

and hold for 5 seconds. Then the patients relax the wrist and let it descend into fl exion. Patients are instructed to exercise 25 times per waking hour. Four weeks after surgery, active digital fl exion and extension are instituted with the dorsal blocking splint still on and the tenodesis splint is discontin-ued. One week later, active composite fi st followed by active extension of the wrist and digits is added to the program. When both fl exor tendons are repaired in the digital sheath, differential motion of the two tendons should be practiced. Shifting the fi nger postures from straight, hook, and fi st posi-tions generates differential gliding of the two tendons.

Early active motion In the late 1980s and early 1990s, protocols containing early active tendon motion components emerged. One requirement is that the tendon repairs be strong enough to tolerate tension during the motion. In 1989, the Belfast surgeons devised an active motion protocol, 210 which was later known as the “ Belfast method. ” Postoperatively, a splint is applied from the elbow to the fi ngertips with the wrist in midfl exion, the MCP joint at slightly less than 90 ° fl exion, and the IP joints straight. The light dressing is removed from the digits and exercises are started 48 hours after surgery. Under supervision, the exercises consist of two passive movements followed by two active movements and are performed at 2-hour intervals. The hand is rested in elevation overnight. During the fi rst week, the PIP joint is actively fl exed through about 30 ° and the DIP joint through 5 – 10 ° . In subsequent weeks, the range of active motion is gradually increased. The splint is removed by the sixth week and blocking exercises of the IP joints are initiated when necessary. Variants of the Belfast method have been reported. In one of the variants – the “ Billericay regime ” – the wrist and the MCP joint are kept in a splint at 30 ° fl exion respectively, and the splint is removed by the fi fth week. The patient is instructed to perform 10 repetitions of the active fi nger fl exion exercise hourly. 211

Author ’ s preferred combined active – passive method (Nantong regime) After surgery, the hand is protected in a dorsal thermoplastic splint, with the wrist at 20 – 30 ° fl exion, MCP joint at slight fl exion, and the IP joints in extension for the initial 2.5 weeks ( Fig. 9.39 ) . 19 We do not encourage patients to move the fi nger in the initial postoperative days; exercise starts at 3 – 5 days (in most cases, at 4 or 5 days) after surgery. Patients are instructed to fl ex the fi nger actively with gentle force 20 – 30 times in the morning, noon, evening, and before sleep, up to the range they feel comfortable with (usually from full extension to one-third or one-half of fl exion range, and even increasing to two-thirds if achieved with ease). Active fl exion over full range is not encouraged, unless it can be achieved very easily. At the beginning of each exercise session, the fi nger is passively fl exed 10 or more times to lessen the overall resistance of fi nger joints and soft tissues during subsequent active fl exion. In this 2.5-week period, full active extension is particularly encouraged, and prevention of extension defi cits rather than achieving full range of active fl exion is emphasized.

After 2.5 weeks, a new thermoplastic splint is made, and the wrist is splinted at 30 ° extension ( Fig. 9.39 ). Exercise of

fi nger fl exion, both passively and actively, is emphasized in this period. Active motion up to the midrange is required, and can proceed up to two-thirds (or full range). However, digital fl exion from the midrange to full range, in particular over the fi nal one-third of the fl exion range, is usually achieved pas-sively. In this period, we ensure passive fl exion over a full range to prevent joint contracture and active fl exion over an increasingly greater range, gradually approaching full fl exion range, but discourage active forceful fl exion of the fi nger over the fi nal range where the tendon is subjected to the greatest load and is more vulnerable to rupture. Differential FDS and FDP motion exercise is encouraged throughout the fi rst 5 weeks. From the sixth week, full active fi nger fl exion is encouraged (which can be started earlier when fl exion is judged to have less resistance). From 6 to 8 weeks, the splint is removed or used only at night.

The protocols described above represent several distinct categories of exercise. From communications with many hand surgeons and therapists, I have found that hand centers around the globe use variants of these protocols. Motion regimes for zone 4 and 5 repairs are generally not as complex as those described above. There is not yet universal agreement regarding the timing of initiating rehabilitation and frequency of digital fl exion – extension motion. Theoretically, tendon adhesions start to develop from 10 days to 2 weeks after surgery. No studies have yet proven the necessity of starting exercise on the fi rst day after surgery. It seems equally reason-able to commence exercise slightly later, though still within 1 week of surgery. Likewise, no studies have identifi ed the optimal frequency of motion in each exercise episode or whether more frequent exercise leads to better results.

Experimental evidence supporting later commencement of tendon motion has been offered by Zhao et al. 118 of the Amadio group, and my colleagues Xie et al. 119 and Cao et al. 122 Digital edema increases resistance to motion, which peaks at 3 – 5 days. 120 – 122 Both Zhao et al. 118 and Cao et al. 122 suggest that motion should be commenced later (5 days after surgery).

Outcomes, prognosis, and complications

Review of outcomes reported over 20 years showed excellent or good active range of fi nger motion in more than three-fourths of primary tendon repairs. 14,17,19 – 21,25,210 – 233 Nevertheless, repair ruptures were documented in a majority of the reports. In the earlier part of this period, the rupture rates ranged from 4 to 10% in the fi nger fl exors and from 3 to 17% in the FPL tendon of thumbs. 14,17,210 – 230 Adhesions remained the most common complication, preventing satisfactory return of active joint motion. Finger joint stiffness was reported fairly fre-quently as well. It is worth noting that most of these reports came from the fi nest hand centers in the world, and each team was supervised by at least one surgeon with expertise in treat-ing tendon injuries. Therefore, the outcomes in a general hos-pital setting may refl ect a lower level of success. Flexor tendon repairs might have been unsuccessful in a larger proportion of patients, with a greater incidence of repair ruptures, adhe-sion formations, or digital joint contracture.

Nevertheless, the past 20 years have seen impressive improvements in outcomes of fl exor tendon repairs. In the



randomized trial between 1996 and 2002. They documented signifi cantly greater range of digital motion, smaller digital fl exion contractures, and greater patient satisfaction in the active motion group than in the passive motion group. Associated nerve injury, multiple digit injuries, and smoking were factors leading to poorer outcomes. Patients treated by a certifi ed hand therapist had better motion and less severe contractures. Two digits had tendon ruptures in each group. The study supports the combination of multistrand tendon repair and postoperative early active motion therapy in zone 2 primary fl exor tendon repairs.

Of note, reports of multistrand core sutures in recent years documented minimal or zero repair ruptures. A stronger sur-gical repair combined with release of the pulleys offered great safety to the postoperative active motion exercise. After com-bined use of multistrand repairs and pulley releases, most

Fig. 9.39 Author ’ s combined passive – active tendon motion protocol. This protocol is divided into two 2.5-week periods. In the fi rst 2.5 weeks, with wrist in slight fl exion, fi nger extension is emphasized. Only partial active digital fl exion is allowed, but full range of passive motion is implemented. In the second 2.5 weeks, with wrist in extension, full active fi nger fl exion is encouraged. This protocol incorporates the concept of synergistic wrist and fi nger motion. When the wrist is fl exed, fi nger extension is less tensed; when the wrist is extended, fi nger fl exion is less tensed.

Emphasize on full active digital flexion

Emphasize on full digital extension

Partial active digital flexion and full passive digital flexion

The Second 2.5 Weeks

The First 2.5 Weeks

late 1980s and early 1990s, Small et al. 210 and Cullen et al. 212 used a two-strand repair and postoperative active motion and had repair ruptures in 6 – 9% of the repairs, with overall good or excellent results in 78% of digits. Elliot et al. 211 reported a series of 233 patients with complete division of the digital fl exor tendons, treated with a two-strand core repair with a controlled active motion regimen. Thirteen (5.8%) fi ngers and fi ve (16.6%) thumbs suffered tendon ruptures during the mobilization. In the same period, multistrand core repairs were reported by Savage and Risitano, 14 and Tang et al., 17,214 together with active or active – passive motion therapies.

Trumble et al. 233 used a four-strand Strickland core suture and a running epitendinous suture to repair zone 2 fl exor tendon lacerations in 119 digits (103 patients) and examined postoperative therapies in a multicenter prospective


201Secondary procedures

cases returned to good to excellent active range of digital motion with zero tendon ruptures ( Box 9.4 ). 19,24,25 My own clinical outcomes also indicate that good to excellent return of function can be achieved fairly consistently by means of multistrand tendon repairs, venting of pulleys, and well-designed combined passive and active motion protocols.

Strickland and Glogovac criteria ( Table 9.2 ) are most com-monly used methods in assessment of outcomes. 15 Moiemen and Elliot criteria ( Table 9.2 ), 20 which specifi cally evaluate the active range of fl exion of the DIP joint, are favored by sur-geons who record outcomes of zone 1 repair. The total active range of motion (TAM) method proposed by the American Society for Surgery of the Hand is also used, and the Buck – Gramcko method is used often by German-speaking hand societies. 153 Among the less popular methods currently used are White, Tubiana, and tip-to-palm distance methods. I cur-rently use a criterion that implements a more stringent measure of range of active fi nger motion, as well as grip strength and quality of motion, into the grading system ( Table 9.2 ). 19

Outcomes of fl exor tendon repairs are affected by patient age, extent and zones of injuries, timing of the repairs, post-operative exercise, and the expertise of the surgeon. Results of tendon repairs in children are generally better than those in adults. Tendon repairs associated with extended soft-tissue damage or accompanied by phalangeal fractures are likely to have worse outcomes.

Secondary procedures Secondary tendon repairs are achieved by free tendon graft-ing, or a staged reconstruction. These procedures are reserved

for served tendons that could not be repaired primarily or for lengthy tendon defects. These techniques, developed by the early masters of hand surgery, 38 – 42,234 – 244 remain largely unchanged today despite refi nements in tendon junction methods, use of novel suture meterials, and widespread adoption of postsurgical rehabilitation in recent decades ( Box 9.5 ). 245 – 249

Free tendon grafting

Indications and contraindications

Most traumatic lacerations of the digital fl exor tendons are now treated with end-to-end tenorraphy primarily. Only some cases require secondary repairs by means of free tendon grafting. Tendon grafting is indicated: (1) when the lacerated tendons are not treated during primary or delayed primary

Function is graded as excellent or good when either the grip strength is – or quality of motion is “ poor. ”

Table 9.2 Criteria of assessment of functional outcomes of fl exor tendon repairs

% return of motion *

Grip strength †

Quality of motion ‡

Function grade

Strickland criteria (1980)

85 – 100 ( > 150 ° ) Excellent

70 – 84 (125 – 149 ° ) Good

50 – 70 (90 – 124 ° ) Fair

0 – 49 ( < 90 ° ) Poor

Moiemen – Elliot criteria (2000) for zone 1 injuries, the distal interphalangeal (DIP) joint only

85 – 100 ( > 62 ° ) Excellent

70 – 84 (51 – 61 ° ) Good

50 – 70 (37 – 50 ° ) Fair

0 – 49 ( < 36 ° ) Poor

Tang criteria (2007)

90 – 100 + Excellent or good Excellent + – Poor Excellent –

70 – 89 + Excellent or good Good + – Poor Good –

50 – 69 Fair

30 – 49 Poor

0 – 29 Failure

* Percentage return of the normal (contralateral) hand. Strickland and Tang criteria use sum of active range of motion of the DIP and proximal interphalangeal joints. Moiemen – Elliot criteria use motion of the DIP joint only. † Grip strength is recorded as + when it is greater than that of the contralateral hand (the nondominant hand), or over 70% of that of the contralateral hand (dominant hand). Otherwise, grip strength is considered abnormal and recorded as – . ‡ Quality of motion is rated on the basis of direct observation of fi nger motion by surgeons. It is recorded as “ excellent ” when all three aspects – motion arc, coordination, and speed – are normal; as “ good ” when any two are normal; and as “ poor ” when only one, or none, is normal.

Box 9.4 Methods to optimize outcomes

• Master tendon anatomy in detail and use atraumatic techniques throughout surgery

• To expose the tendons, open a window in the synovial sheath, or open the A2 pulley partially or the entire A4 pulley if the repair site overlaps or locates slightly distal to these structures

• May release the distal two-thirds parts of the A2 pulley, where it is the most narrow and most constrictive to the tendons, when the fl exor digitorum profundus tendon is cut just distal or under the pulley. A portion of this pulley should be kept intact during surgery

• Adopt a stronger core suture method, with suffi cient suture purchase and appropriate locks on tendons

• Add peripheral sutures to smooth the repair and to prevent gap formation

• Properly combine passive and active fi nger motion into postoperative motion protocols. Fully extend and fl ex the fi nger passively, followed by active fi nger fl exion over a certain range. Active motion over the fi nal one-half or one-third is discouraged in the initial weeks to avoid tendon overload (rupture). Postoperatively, apply motion therapy for at least 5 – 6 weeks

• Passive fi nger motion before active motion substantially decreases the overall resistance to digital motion, lessening the chance of repair ruptures during active motion

• Surgical tendon repairs are performed by experienced surgeons, and the unit should have established postsurgical rehabilitation guidelines



Fig. 9.41 Three common donors of tendon grafts: (A) palmaris longus tendon; (B) plantaris; and (C) toe extensors.

A B C

Box 9.5 Secondary surgery: grafting and staged reconstruction

Indications • Tendon injuries not treated within about 1 month after injuries • Rupture of the tendon repairs at primary or delayed primary

stages • Tendon injuries not indicated for primary repair • Badly scarred digits are indicative for staged tendon

reconstruction

Essential requirements • Supple passive motion of the hand • Soft-tissue conditions: good • Suffi cient time passed after initial tendon injury: 3 months

Contraindications • Joint motion is very limited (but may be suitable for staged

reconstruction) • Presence of soft-tissue wounds or defects, and fractures not well

healed

stage; (2) when the primary repairs have ruptured and cannot be re-repaired directly; and (3) in the cases not indicative of primary tendon repairs because of severe contamination, infection, lengthy loss of tendon substance, extensive destruc-tion of the pulleys, or accompanying injuries. Patients who have serious scarring in the tendon bed or failed previous efforts at secondary fl exor tendon procedures are appropriate for a staged tendon reconstruction, rather than one-stage tendon grafting. Surgeons sometimes need to decide accord-ing to intraoperative fi ndings, such as severity of scarring and pulley destruction.

Before surgery is attempted, the soft-tissue wound should be well healed, with supple passive motion of the hand. Physical therapy is prescribed to improve the range of motion of the digits if passive joint motion is limited substantially. Boyes and Stark 42 classifi ed the conditions associated with the cases of tendon grafts and surgical prognosis is worsened by poor hand condition. Lack of passive range of joint motion is contraindicated for one-stage tendon grafting, but may be suitable for staged tendon reconstruction. The timing of tendon grafting is usually 3 months after injury.

Donor tendons

The donors are palmaris longus, plantaris, long toe extensors, or in rare instances the FDS tendon from a normal fi nger ( Figs 9.40 and 9.41 ) . The palmaris longus tendon (about 15 cm) from the ipsilateral limb is a frequently used donor and is appropriate for a palm-to-fi ngertip graft. It can be easily har-vested through a short transverse incision over the tendon just proximal to the fl exion crease of the wrist. The tendon is divided and grasped with a hemostat, while a tendon stripper is advanced slowly into the proximal forearm. Care must be taken to protect the median nerve trunk lying beheath the tendon and its cutaneous branch of the median nerve. 250 Because this tendon is absent in about 15% of all hands, 251 examination to confi rm its presence is essential before surgery. The plantaris tendon is equally satisfactory for a graft, which is obtained by an incision medial to the Achilles tendon and use of a tendon stripper. The length of this tendon (25 cm) is well suited for a long distal forearm-to-fi ngertip graft.

Fig. 9.40 Harvesting a tendon graft through a small skin incision, using a tendon tripper.

Palmaris longus tendon

Skin incision

Tendon stripper

However, this tendon is absent in 7 – 20% of limbs, and its presence cannot be predicted preoperatively. 252,253 Extensor digitorum longus tendons to the second, third, and fourth toes, the extensor indicis proprius, the extensor digit quinti proprius and the FDS tendon to the fi fth fi nger can be used



as well. In my clinic, I use the palmaris longus tendon most frequently and place the proximal junction in the palm.

Operative techniques

The fl exor tendon is exposed through a volar Bruner ’ s inci-sion or the midaxial approach. 254 – 258 Integrity of the major annular pulleys is important to the function of the graft. At least the A2 and A4 pulleys should be preserved. If possible, other annular pulleys such as A1 or A3 and a part of the syno-vial sheath are preserved to foster better gliding of the grafted tendon. If a series of annular pulleys are found to be destroyed, reconstruction of pulleys is necessary. Most cases requiring reconstruction of multiple pulleys need to proceed to staged tendon reconstruction.

The distal junction of the graft is placed at the fi ngertip. The common method is to suture the graft directly to the residual FDP stump or bury it under an osteoperiosteal fl ap in the volar phalanx ( Fig. 9.13 ). 258 – 260 In the latter case, the straight needles are passed through the distal phalangeal drill hole and exit over the proximal portion of the nail. After emerging from the nail surface, the needles are passed through a gauze pad or a sponge, and through the holes of an overlay-ing button. The sutures are tied over the button to anchor the graft. Additional sutures are used to secure the FDP tendon stump to the graft. Alternative methods are available, as shown in zone 1 repair ( Fig. 9.13 ). 156,158,159,244 In children, drill holes at the distal phalanx may damage the open epiphyses; the graft is sutured directly to the stump of the profundus instead. Either at the palm or in the forearm, the proximal junction of the graft is achieved by a Pulvertaft weave suture to the proximal stump of the fl exor tendon ( Fig. 9.42 ) . Placement of the junction at the palm requires only a shorter graft and preserves the function of lumbrical muscles. Care is taken to avoid suturing the tendon to the lumbrical muscle, because this tends to increase the tension in the muscle. Placement of the junction above the wrist allows easy adjust-ment of the tension of the graft, and the scar may be less severe. In the author ’ s experience, a Pulvertaft weave suture is appropriate for the proximal junction in both areas ( Fig. 9.43 ) , and the fi nger is held in slightly greater fl exion than in the resting position when the proximal stump is sutured ( Fig. 9.44 ) .

Postoperatively, the wrist is held in a position of 30 – 40 ° fl exion, with the MCP joints fl exed to 60 – 70 ° , and the IP joints at rest in almost full extension. The traditional recommenda-tion is 3 weeks of immobilization within a dorsal splint applied from the fi ngertip to below the elbow, followed by active exercise of the digits with the protection of a dorsal blocking splint. Some surgeons advocate passive or active fi nger motion under cautious supervision from a few days after surgery if the graft junctions are strong. Most surgeons still prefer to immobilize the grafted digits for at least 3 weeks to avoid tension on the tendon and to allow some revasculari-zation of the graft. More vigorous exercise can be instituted at 6 weeks after surgery.

The need for tendon graft or reconstruction is controversial when the superfi cialis tendon is fully functional, but the FDP tendon is cut and has not been repaired directly within 3 – 4 weeks of trauma. 261 – 267 There is a risk of losing function if a profundus graft fails. However, such operations are worth the risk in selected cases, such as in young people with a

Fig. 9.42 Skin incision and the method of free tendon grafting to reconstruct the function of digital fl exion. As many annular pulleys as possible are preserved. (A) The tendon junctions are placed outside the fl exor sheath region. To make a proximal junction of the graft with the end of a digital fl exor tendon, the Pulvertaft weave technique is commonly used (shown in detail in B). The junction is placed at either palm or distal forearm. The graft is weaved with the digital fl exor through holes in the tendons created by a knife (B, i – iii).

A

B

Distal tendon to

bone junction

Proximal tendon to

tendon junction



tendon continuity and gliding. The techniques were developed in the middle of the 20th century by Bassett and Carroll, 44 Hunter, Paneva-Holevich, Schneider et al. 268 – 279 This operation consists of procedures in two stages. In the fi rst stage, the tendon and scar from the tendon bed are excised, but the pulleys are preserved or reconstructed. A Dacron-reinforced silicone tendon implant is inserted into the tendon bed to maintain the tunnel and to stimulate the forma-tion of a mesothelium-lined pseudosheath. Following matura-tion of the sheath, a tendon is grafted in lieu of the implant in the second stage.

Techniques: the fi rst stage

The involved fi nger is exposed through a volar zigzag incision and the incision is continued to the lumbrical origin level of the palm ( Fig. 9.46 ) . The tendons and sheath (pulleys) are usually found embedded within scars. The tendons are excised with a 1-cm stump of the profundus tendon retained at its distal insertion. The critically located annular pulleys are carefully dissected out of scars. All potential useful pulley materials are preserved. When a series of pulleys are damaged, critically located pulleys (A2 and A4) should be reconstructed; this is an important part of the reconstruction. One method is

reasonable need for active DIP joint fl exion. The procedures are similar to those described above. A thinner donor tendon is preferable and the A2 pulley can be shortened, but a series of pulleys are preserved ( Fig. 9.45 ) . Alternatively, one slip of the FDS tendon can be removed to favor passage of the graft. During the procedure, while passing the graft through the FDS tendon, injury may occur that results in the formation of adhesions and a loss of fi nger function. Overall, caution must be exercised with patient selection. Patients with intact super-fi cialis tendon may adapt nicely and require no treatment. Surgeons should fully inform patients about expected gain of function versus risks of this operation.

When the superfi cialis tendon is intact and the DIP joint is not stable, the DIP joint can be fused or tenodesed in slight fl exion. In the presence of a functional FDS tendon, the com-bination of MCP and PIP joint motion produces approxi-mately 85% of the arc covered by the fi nger in fl exion.

Staged tendon reconstruction

Indications

This operation is indicated in cases with badly scarred digits, as a result of injury or multiple failed attempts to restore

Fig. 9.43 A case of free tendon grafting with a Pulvertaft weave junction of the graft with a digital fl exor tendon in the palm. (A) The graft was weaved into the digital fl exor tendon. (B and C) Two sutures were added in either side of the graft and the digital fl exor. (D) Completion of the weave tendon repair.

A B

C D



to use a tendon graft, either a portion of an excised fl exor tendon or the palmaris longus tendon, and wrap it around the phalanx twice to obtain suffi cient width, but place it deeper than the extensor mechanism in the proximal phalanx or superfi cial to the extensors in the middle phalanx ( Fig. 9.47 ). Another method is to make use of one rim of a residual pulley, and a tendon graft or a part of the extensor retinaculum is woven back and forth to form a volar part of the residual pulley. A slip of the FDS tendon can be used to make a pulley as well. In the presence of fl exion contracture of the fi nger joint, check-rein extensions of the palmar plate and the accessory collateral ligaments are divided to release the contracture. The profundus tendon is transected at the midpalm.

A set of tendon implants is then tried to determine the appropriate size of the implant, which is judged by the tight-ness of the digital pulleys and the expected size of the tendon graft in the second stage. In adults, 4-mm implants are often used; these are close in size to the tendon graft. After insertion of the implant underneath the pulleys, the implant should be movable in the tendon bed with minimal resistance. The distal anchor of the implant can be created in several ways ( Fig. 9.48 ) . A second incision is made in the distal forearm. The implant is then passed from the proximal palm to the distal forearm using a tendon passer. After the implant is seated, traction is placed on the proximal end of the implant to make sure that it glides freely. A tunnel is created with blunt dissec-tion proximally over the profundus muscle in the proximal forearm. The implant is laid into this tunnel and a space proximal to the implant is ensured for implant migration during exercise.

Postoperatively, the wrist is held with a short arm posterior splint in slight fl exion (30 ° ) and the MCP joint in marked

Fig. 9.44 Tension status of the fi ngers at the time of suturing the proximal tendon junction of a graft. With the wrist in neutral position, the fi ngers are slightly more fl exed than at the resting position, with each fi nger falling into slightly more fl exion than its radial neighboring fi ngers.

Fig. 9.45 A case of reconstruction of the fl exor digitorum profundus tendon in the presence of an intact fl exor digitorum superfi cialis (FDS) tendon. A palmaris longus tendon was harvested as a graft. A series of pulleys (A4, a part of the A2, and A1) were preserved. The thin palmaris longus tendon fi ts well within the pulleys and intact bifurcating FDS tendon in the fi nger.

Fig. 9.46 (A) In stage 1 an extensive scar is found after exposure. The scar and the tendon are excised. (B) A tendon implant is placed into the scarred tendon bed. The annular pulleys are preserved. The proximal end of the tendon implant is not sutured and is left free.

A

B

Scarred tendon and pulleys

Reconstructed pulleysTendon implant



environment for tendon gliding. Proper tension on the graft is essential for function.

Paneva-Holevich 268 advocated that the FDS tendon should be used proximal to the injury from the same fi nger as the graft source. This procedure evolved to include placement of a tendon implant together with suturing the proximal FDS to the proximal FDP end at the fi rst stage, and implant removal, grafting the FDS into the fi nger at the second stage, which yielded favorable results. 269,279

Postoperatively, the wrist is held in a position identical to that for a tendon graft.

Some surgeons immobilize the hand for 3 – 4 weeks; others favor an early protected motion program initiated days after surgery. Therapy proceeds carefully through passive and light active motion until at least 6 weeks, when the tensile strength of the tendon and its junctures is suffi ciently strong to tolerate more vigorous motion.

Tenolysis

Indications

Tenolysis is indicated when the passive range of digital motion greatly exceeds the range of active fl exion several months after direct end-to-end tendon repair or tendon grafting. 234,280,281 Tendon trauma with severe damage to peritendinous tissues

fl exion. Passive wrist and digital motion can be started 1 week later. By 8 weeks, full activity is permitted, except powerful grip until 12 weeks. In cases with pulley reconstruction, the fi ngers must be protected by circumferential taping or orthoplast rings.

The second stage

The second-stage operation is planned approximately 3 months later. A small incision is made adjacent to the distal implant – tendon junction ( Fig. 9.49 ) . A portion of the previous incision can be used. After disconnecting the implant from the distal FDP tendon stump, the implant is tagged. A free tendon graft is harvested and inserted into the pseudosheath tunnel. Care is taken not to open the pseudosheath proximal to the DIP joint and to avoid injury to any pulleys. The appropriate motor tendon is then selected. The profundus mass is chosen for grafts to the middle, ring, and small fi ngers. For index fi nger reconstruction, the profundus tendon to the index fi nger is chosen as a motor. For thumb reconstruction, the FPL or one of the FDS muscles is used. The proximal junction can be placed in the palm, but in most cases, it is located in the distal forearm. The tendon graft is attached to one end of the implant. The implant is pulled out through the pseudosheath from one end. The distal tendon junction is secured as previ-ously described for free tendon grafting. Placement of the proximal juncture in the forearm offers the graft a favorable

Fig. 9.47 Methods of fl exor pulley reconstruction. (A) Reconstruction of the A2 and A4 pulleys using fl exor tendon grafts passed circumferentially around proximal and middle phalanges. The tendon graft passes deeper to the extensor apparatus at the proximal phalangeal level and superfi cial to the extensors at the middle phalangeal level. (B) A tendon graft is weaved through a remnant of the A2 pulley to reconstruct the A2 pulley. (C) Use of a slip of fl exor digitorum superfi cialis (FDS) tendon for middle digital pulley reconstruction. A B C

Grafts

Graft

Button

Button

FDS tendon

slip

FDS tendon slip

A2 pulley



motion achieved. The exact optimal timing of tenolysis remains controversial. 234,284 – 287 It is reasonable to consider ten-olysis if the desired range of motion is not achieved after 3 months of therapy. At least 3 months should have passed since the direct repair or graft to allow necessary healing and revascularization of tendons, so as to avoid endangering tendon strength. To assess the patient ’ s fi nal function reliably, 4 – 6 months are usually required. 234 However, there is no abso-lute criteria for how poor the range of motion must be to indicate tenolysis. Surgeons should consider the patient ’ s age, occupational requirements, and functionality of the hand in making a decision. Preoperatively, patients should be informed that intraoperative fi ndings may be incompatible with tenoly-sis; thus the surgeons need to proceed to the fi rst step of staged reconstruction on fi nding serious destruction of pulleys or a lengthy lysed tendon segment.

Anesthesia

Active involvement of the patient in assessing tendon mobil-ity and adequacy of release is a key step of surgery. This is achieved by using sedative anesthesia, combined with local anesthesia at the operation area. 234,288 I use 2% lidocaine (without epinephrine) infi ltrated locally in the subcutaneous tissues or as a digital nerve block at the metacarpal level. Patients are awakened easily and cooperate dynamically during surgery. Axillary block or general anesthesia is used if the surgeon expects an extensive operation, such as tenolysis in multiple digits, a staged reconstruction procedure, or if the patient is unlikely to tolerate surgery with local anesthesia.

Operative techniques

Through either a Bruner or midlateral incision, dissection pro-ceeds from the unaffected area to the affected area. Tenolysis requires wider surgical exposure. All limiting adhesions are meticulously divided and care is taken to defi ne the borders of the fl exor tendons. During dissection, some surgeons advise preservation of the sheath as much as possible, but others prefer to excise the synovial sheath. Regardless, the major pulleys should be maintained, and the synovial sheath embed-ded within the scar is removed. It is necessary to maintain the A2 and A4 pulleys at a minimum. If possible, the A3 pulley and its adjacent sheath are also preserved. A variety of instru-ments may aid in dissection of the scarred tendons from inner surfaces of the major pulleys. 288 – 290 Whenever possible, the FDS and FDP tendons are separated from one another. In some cases with severe adhesions, the FDS tendon has to be resected locally. Dissection is continued until normal tissues are revealed and no scar around the tendon is visible. Adequacy of the release is then checked by active digital fl exion of the patient or by a gentle proximal traction on the proximal part of the tendon ( Box 9.6 ). A separate proximal incision in the palm can be created to pull the tendon. The quality of the tendon and integrity of the pulleys are checked. If tendon continuity is maintained only by scar or greater than one-third of the tendon width is lost, the tendon is unlikely to function properly and the case should proceed to staged tendon reconstruction. If the critical pulleys are destroyed, it is appropriate to proceed to pulley reconstruction.

Over the years, many attempts have been made to develop strategies to block or limit adhesion formation. 291 – 302 Thus far,

or compound injuries (such as digital or palm replantation) has a greater chance of adhesion formation, thus is more likely to require tenolysis as later surgery. 282 Children can also be candidates for this surgery. 283

The prerequisites for this operation are: (1) all fractures are healed; (2) wounds have reached equilibrium with soft, pliable skin and subcutaneous tissues, and minimal reactions around the incision scars; and (3) joint contractures must have been corrected and a normal or near-normal passive range of digital

Fig. 9.48 Distal junction of the tendon implant in stage 1. (A) The distal junction wire method. A fi gure-of-eight suture of a monofi lament wire (no. 32) is placed in the implant and sutured to the fl exor digitorum profundus stump. Additional sutures are supplemented on each side of the implant. (B) Screw-plate fi xation method. A self-tapping Woodruff screw (2 mm) is used, inserted into a drill hole in the phalanx using a K-wire (0.035-inch (0.1 cm)).

A

B

Distal tendon stump

Tendon implant

Tendon implant

15˚-20˚

0.035 wire



catheters may be considered for patients with low pain thresh-olds or those undergoing extensive operations. Repeated digital nerve block can also be used. 304 Active motion of the fi ngers can begin on the fi rst day after surgery. Some surgeons advocate waiting for several days or until soft-tissue infl am-mation and pain subside to start motion.

Postoperative tendon movement is critical to the success of tenolysis and remains the most effective method to prevent recurrence of adhesions. 305 – 309 The amplitude, frequency, and forces of motion should be decided based on intraopera tive fi ndings. The surgeons should directly discuss with the therapists to consolidate a therapy program. A tendon appearing nearly normal in a minimally scarred bed with a strong pulley system is appropriate for a more vigorous motion protocol. When a tendon is of poor quality – with a dense scar, a lysed segment, or a decrease in tendon caliber – or if pulleys have been reconstructed, gentle active motion or delayed initiation of the fi nger motion is indi-cated. 234 In this instance, a “ place and hold ” maneuver after passive digital motion into full fl exion is useful to reduce tension and the likelihood of tendon disruption. Passive motion of the fi ngers is helpful in preventing fi nger joint contractures and in decreasing the resistance to active fi nger movement. The motion program is usually continued for 4 – 6 weeks.

few of these attempts have reliably reduced adhesions clini-cally and are used routinely. Some surgeons favor the use of steroids. 286 One multicenter clinical trial indicated the benefi ts of using a hyaluronan gel in reducing adhesions after tenolysis. 303

Postoperative treatment

Oral analgesics usually alleviate pain during the postopera-tive period. Transcutaneous placement of local anesthetic

Fig. 9.49 In stage 2, the tendon implant is replaced by a tendon graft. (A) The implant is exposed through a small incision at the distal part of the fi nger. After being disconnected from the fl exor digitorum profundus tendon stump, the implant is sutured to the tendon graft. The implant is pulled proximally through the newly formed sheath to lead the grafted tendon. (B) The graft has been tunneled in the hand. The distal tendon junction is completed similarly to tendon grafting. The proximal junction of the graft is made.

A

B

Autogenous tendon graft

Tendon graft

Tendon implant

Box 9.6 Tenolysis: technical pearls

• Local anesthesia is advised, to allow active fi nger fl exion when needed during surgery

• Ensure adequate surgical exposure and start dissection from the border of adhesions

• Strictly preserve the critically located annular pulleys (A2 and A4 as a minimal)

• Check mobility of released tendon to confi rm adequacy of surgery before completion

• Postoperative motion is paramount to the success of this procedure

• Rigor of motion regimes is decided according to intraoperative fi ndings of the released tendons. Motion exercise should always be applied and continued for 4 – 6 weeks



Access the complete references list online at http://www.expertconsult.com

11. Verdan CE . Primary repair of fl exor tendons . J Bone Joint Surg (Am) . 1960 ; 42 : 647 – 657 .

14. Savage R , Risitano G . Flexor tendon repair using a “ six strand ” method of repair and early active mobilization . J Hand Surg (Br) . 1989 ; 14 : 396 – 399 .

19. Tang JB . Indications, methods, postoperative motion and outcome evaluation of primary fl exor tendon repairs in zone 2 . J Hand Surg (Eur) . 2007 ; 32 : 118 – 129 . This article provides a comprehensive and updated review of the current indications for primary tendon repairs in zone 2. The author ’ s techniques of multistrand repairs and rehabilitation are detailed. Most importantly, the author defi nes the needs, mechanical basis, and areas of releasing the critical parts of the major digital annular pulleys to facilitate tendon repairs. The author highlights the importance of releasing the critical pulley parts and strong surgical repairs in achieving predictable primary fl exor tendon repairs in this most diffi cult area. Subdivision of zone 2 and novel criteria for outcome evaluation are also presented in this article.

25. Giesen T , Sirotakova M , Copsey AJ , et al . Flexor pollicis longus primary repair: further experience with the Tang technique and controlled active mobilisation . J Hand Surg (Eur) . 2009 ; 34 : 758 – 761 . This clinical study reported the most up-to-date clinical outcomes of repairs of lacerated fl exor pollicis longus (FPL) tendons from a renowned center dealing with fl exor tendon injuries. These authors have made a series of reports of their results in treating FPL injuries over the past two decades; this most recent report documents their outcomes in 50 FPL injuries. With a six-strand core tendon repair alone (without peripheral repairs), they achieved good or excellent functional recovery in 80% of thumbs, with zero tendon rupture with an active motion regime. These are the best clinical results of FPL tendon repairs reported thus far. It is worth noting that the authors did not elaborate peripheral sutures in these FPL tendon repairs, and the oblique pulley in the thumb was vented to accommodate tendon repairs.

42. Boyes JH , Stark HH . Flexor-tendon grafts in the fi ngers and thumb. A study of factors infl uencing

results in 1000 cases . J Bone Joint Surg (Am) . 1971 ; 53 : 1332 – 1342 . This classic article reported perhaps the largest case series of free tendon grafting in the fi ngers and thumbs. The authors analyzed the factors infl uencing the prognosis for free tendon grafting and showed that the tendon-grafting procedure used can produce clinically acceptable function. However, hand conditions are extremely important. Prognostic factors include conditions of the soft tissues and joints. Extensively scarred tendon bed and joint damage led to the worst prognosis after tendon graft surgeries.

46. Hunter JM , Salisbury RE . Flexor-tendon reconstruction in severely damaged hands. A two-stage procedure using a silicone-Dacron reinforced gliding prosthesis prior to tendon grafting . J Bone Joint Surg (Am) . 1971 ; 53 : 829 – 852 .

150. Elliot D . Primary fl exor tendon repair – operative repair, pulley management and rehabilitation . J Hand Surg (Br) . 2002 ; 27 : 507 – 513 . This article summarized developments in surgical tendon repair techniques, methods of venting the annular pulleys, and active tendon motion regimes for primary fl exor tendon repairs in the hand. Of particular clinical interest, the authors reviewed methods of early active or combined passive – active tendon motion (representing a current trend in digital fl exor tendon rehabilitation) and the pulley-venting procedure that the author and his colleagues have been using in their practice.

172. Tang JB . Clinical outcomes associated with fl exor tendon repair . Hand Clin . 2005 ; 21 : 199 – 210 .

205. Kleinert HE , Schepel S , Gill T . Flexor tendon injuries . Surg Clin North Am . 1981 ; 61 : 267 – 286 .

234. Strickland JW . Delayed treatment of fl exor tendon injuries including grafting . Hand Clin . 2005 ; 21 : 219 – 243 . This article provides an update on historical developments of surgical techniques, the author’s personal approaches, and current practice of these secondary repair procedures, which are generally considered classic operations. Little has changed over recent decades.


178.e1Historical perspective

Historical perspective Documentation and treatment of tendon injuries date back to antiquity. Hippocrates and other ancient physicians observed a slender white tubular structure entering skeletal muscle, and considered this to be a nerve. Galen, who lived in the Roman Empire in the second century, advised physicians not to repair tendons because it was believed this would result in pain, twitching, and convulsions of the limb. Over the follow-ing 15 centuries, surgeons were largely infl uenced by the teaching of Galen. The seminal challenge to Galen ’ s assertion did not occur until the mid 18th century when Von Haller showed that placing a suture in a canine Achilles tendon did not have detrimental effects. 26

The fi rst experimental investigation of the tendon-healing process was performed in 1767 by John Hunter, who recorded that the canine Achilles tendon healed by the formation of callus, similar to that seen in healing bone. 26,27 However, specifi c studies of fl exor tendon healing within the digital sheath were not started until about 150 years later, in the early 20th century. Around 1920, Salomon observed poor tendon healing of sutured canine fl exor tendons. 28 Salomon thus advocated leaving a defect in the tendon sheath to allow contact between the repaired tendon and the subcutaneous tissue. 29 Bunnell and Garlock observed the frequent occur-rence of restrictive adhesions at the fl exor tendon laceration site. 30 – 32 Bunnell coined the term “ no man ’ s land ” to describe the region where fl exor tendons passed through the digital sheath and advised surgeons to be cautious when repairing tendons in this region. In 1940, Mason advised specifi c condi-tions for repairing lacerated digital fl exor tendons, which included never repairing both tendons, wide excision of the overlying sheath, and adequately eliminating contaminates from the wound. 33 Because of the generally unsatisfactory results of primary fl exor tendon repairs, many surgeons pre-ferred tendon grafting, despite the fact that a few surgeons had demonstrated that primary surgery was practicable at that time.

In the early half of the 20th century, repairing lacerated tendons within the digital sheath was predominantly by means of secondary tendon grafting. The fi rst series of fl exor tendon grafts in the hand was reported by Lexer in 1912. 34 He used grafts to repair fl exor tendons after rupture, old lacera-tions, infection, and cases with ischemic contracture. In 1916, Mayer published articles that have served as the basis of the present-day concepts of free tendon grafting. 35 – 37 He empha-sized the need for existing surgical techniques, direct juncture of the tendon to bone, the use of adequate muscle as a motor, and preserving peritenon around a graft to lessen adhesions. In 1918, Bunnell published a classic article on tendon grafting in which atraumatic technique, a bloodless fi eld, perfect asepsis, and preservation of pulleys were emphasized. 30 The surgical techniques of tendon grafting were subsequently modifi ed by various leaders in the fi eld, including Pulvertaft, 38 Graham, 39 Littler, 40 Boyes, 41 and Stark. 42

In an effort to combat serious scarring in the tendon gliding bed in which conventional one-stage free tendon graft likely failed to restore tendon function, various materials have been implanted into the fi ngers to stimulate formation of a smoother tendon gliding bed. In 1936, Mayer inserted a celloidin tube into a seriously scarred tendon gliding bed, and after 4 – 6

weeks of implantation he then introduced a tendon graft. 43 Mayer introduced the pseudosheath concept. In the 1950s Bassett and Carroll began working with fl exible silicone rubber rods to build pseudosheaths in badly scarred fi ngers, adding passive motion to this procedure. 44 This method was later refi ned into a two-stage tendon reconstruction by Hunter in the 1960s. 45 Hunter and Salisbury 46 also developed the active tendon implant. These implants and two-stage recon-struction procedures are still used currently, and are effective for patients with badly scarred digits and as a salvage proce-dure after other surgery attempts have failed.

It was not until the 1960s that reports of surgical techniques and outcomes of primary repair from Verdan 11 and Kleinert et al. 12 became the turning point in establishing the practice of primary repair of digital fl exor tendons. The emerging popu-larity of primary tendon repair stimulated experimental studies to elucidate mechanisms of the healing process. In the 1970s and 1980s, Manske et al. demonstrated diffusion of nutrients through synovial fl uid to be an effective source of nutrition of intrasynovial tendon, thus obviating the need for vascularization in the healing process. 47 – 50 Matthews and Richards observed healing of lacerated rabbit fl exor tendons within the intact digital sheath in the absence of adhesions. 5,51 – 54 Lindsay et al. noted that both epitenon and endotenon cells proliferate and migrate to the laceration site, and subsequently bridge it. 5,55 – 57 Lundborg et al. demonstrated healing of lacer-ated fl exor tendon segments when placed within the synovial environment of the knee joint or in a synthetic membrane pouch placed in a subcutaneous pocket of the back of the rabbit. 6,7 In the 1980s, Manske, Lesker, Gelberman, and Mass and others demonstrated healing of lacerated fl exor tendon segments of different animals when placed in tissue culture in the complete absence of extrinsic cells. 9,10,58 – 61

In the last three decades, major advances in the fi eld of fl exor tendon repairs were made with respect to the develop-ment of novel surgical repair techniques, accumulation of biomechanical information regarding tendon repairs or gliding mechanisms, modifi cations of postsurgical rehabilita-tion methods, and an emerging trend of exploring biological approaches to enhance tendon healing. In 1985, Savage 13 pub-lished an infl uential experimental study that later stimulated a widespread interest in developing multistrand suture tech-niques to repair the tendon. 62 – 74 The cruciate repair, a simple yet strong four-strand repair developed by McLarney et al. 16 in the late 1990s, is used in many hand centers. In the same period, multistrand repair using Tsuge ’ s looped suture lines, as developed by Lim and Tsai, Tang (and its modifi cation, M-Tang method), 17 – 19,68 have been used by surgeons in hand centers in Asia, Europe, and North America. In 1995 and 1998, Tang 22 and Kwai Ben and Elliot 23 presented an anatomical study and clinical results of the release of a major fl exor pulley (A2) to accommodate gliding of the repaired tendons, respec-tively. Elliot and Tang also proposed venting the A4 pulley when the tendon repairs are in the areas. 19,23

The fl exor tendons were divided into fi ve zones by Verdan in the 1960s. 11 In the 1990s, subdivisions of zone 1 by Moiemen and Elliot 20 and zone 2 by Tang 21 were added to the existing zoning system, in order to describe the location of injuries and repairs more specifi cally. These zoning and subzoning systems provide hand surgeons with the nomenclature to document tendon injuries and outcomes, and discuss the principles of treatment.

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178.e2 SECTION II • • Flexor tendon injury and reconstruction9

In the past 30 years, biomechanics of the fl exor tendon system has become a subject of intense interest for both sur-geons and basic scientists. A large volume of information regarding tendon gliding and repair biomechanics has been obtained, 74 – 122 including surgical repair techniques (mainly from the labs of Gelberman, Manske, Mass, McGrouther, Tang, Trumble, and Wolfe), gliding resistance of tendons within the sheath or against annular pulleys (Amadio and Tang), mechanics of the pulleys (Amadio, Mass, and Tang), postsurgical rehabilitation (Amadio and Boyer), and edema formation (Tang).

In recent years, investigations exploring molecular events in the tendon-healing process, tendon tissue engineering, and

biological approaches to enhance the healing came to the center stage of basic science investigations. Chang et al. reported a series of investigations exploring the function of growth factors in tendon healing, molecular methods to prevent adhesions, and tendon tissue engineering. 123 – 135 Tang and colleagues performed a series of studies of molecular events in tendon healing and gene therapy approaches to enhance strength or limit adhesions. 136 – 146

A comprehensive history on the development of fl exor tendon repairs has been covered in more detail in the reviews written by Verdan (1972), 147 Manske (1988), 148 Strickland (2000), 149 Elliot (2002), 150 Manske (2005), 26 and Tang (2007). 19


209.e1References

References 1. Potenza AD . Tendon healing within the fl exor digital

sheath in the dog . J Bone Joint Surg (Am) . 1962 ; 44 : 49 – 64 . 2. Peacock EE . Fundamental aspect of wound healing

relating to the restoration of gliding function after tendon repair . Surg Gynecol Obstet . 1964 ; 119 : 241 – 250 .

3. Peacock EE . Biological principles in the healing of long tendons . Surg Clin North Am . 1965 ; 45 : 461 – 476 .

4. Potenza AD . Mechanisms of healing of digital fl exor tendons . Hand . 1969 ; 1 : 40 – 41 .

5. Matthews P , Richards H . The repair potential of digital fl exor tendons . J Bone Joint Surg (Br) . 1974 ; 56 : 618 – 625 .

6. Lundborg G . Experimental fl exor tendon healing without adhesion formation – a new concept of tendon nutrition and intrinsic healing mechanisms . Hand . 1976 ; 8 : 235 – 238 .

7. Lundborg G , Rank F , Heinau B . Intrinsic tendon healing. A new experimental model . Scand J Plast Reconstr Surg . 1985 ; 19 : 113 – 117 .

8. Katsumi M , Tajima T . Experimental investigation of healing process of tendons with or without synovial coverage in or outside of synovial cavity . J Niigata Med Assoc . 1981 ; 95 : 532 – 567 .

9. Manske PR , Gelberman RH , Vande Berg J , et al . Flexor tendon repair: morphological evidence of intrinsic healing in vitro . J Bone Joint Surg (Am) . 1984 ; 66 : 385 – 396 .

10. Gelberman RH , Manske PR , Vande Berg JS , et al . Flexor tendon healing in vitro : comparative histologic study of rabbit, chicken, dog and monkey . J Orthop Res . 1984 ; 2 : 39 – 48 .

11. Verdan CE . Primary repair of fl exor tendons . J Bone Joint Surg (Am) . 1960 ; 42 : 647 – 657 .

12. Kleinert HE , Kutz JE , Ashbell TS , et al . Primary repair of lacerated fl exor tendons in “ No Man ’ s Land ” . J Bone Joint Surg (Am) . 1967 ; 49 : 577 .

13. Savage R . In vitro studies of a new method of fl exor tendon repair . J Hand Surg (Br) . 1985 ; 10 : 135 – 141 .

14. Savage R , Risitano G . Flexor tendon repair using a “ six strand ” method of repair and early active mobilization . J Hand Surg (Br) . 1989 ; 14 : 396 – 399 .

15. Strickland JW , Glogovac SV . Digital function following fl exor tendon repair in zone II: a comparison of immobilization and controlled passive motion techniques . J Hand Surg (Am) . 1980 ; 5 : 537 – 543 .

16. McLarney E , Hoffman H , Wolfe SW . Biomechanical analysis of the cruciate four-strand fl exor tendon repair . J Hand Surg (Br) . 1999 ; 24 : 295 – 301 .

17. Tang JB , Shi D , Gu YQ , et al . Double and multiple looped suture tendon repair . J Hand Surg (Br) . 1994 ; 19 : 699 – 703 .

18. Tang JB , Wang B , Chen F , et al . Biomechanical evaluation of fl exor tendon repair techniques . Clin Orthop Relat Res . 2001 ; 386 : 252 – 259 .

19. Tang JB . Indications, methods, postoperative motion and outcome evaluation of primary fl exor tendon repairs in zone 2 . J Hand Surg (Eur) . 2007 ; 32 : 118 – 129 .

This article provides a comprehensive and updated review of the current indications for primary tendon repairs in zone 2. The author ’ s techniques of multistrand repairs and rehabilitation are detailed. Most importantly, the author defi nes the needs, mechanical basis, and areas of releasing the critical parts of the major digital annular pulleys to facilitate tendon repairs. The author highlights the importance of releasing the critical pulley parts and strong surgical repairs in achieving predictable primary fl exor tendon repairs in this most diffi cult area. Subdivision of zone 2 and novel criteria for outcome evaluation are also presented in this article.

20. Moiemen NS , Elliot D . Early active mobilization of primary fl exor tendon repairs in zone 1 . J Hand Surg (Br) . 2000 ; 25 : 78 – 84 .

21. Tang JB . Flexor tendon repairs in zone IIC . J Hand Surg (Br) . 1994 ; 19 : 72 – 75 .

22. Tang JB . The double sheath system and tendon gliding in zone IIC . J Hand Surg (Br) . 1995 ; 20 : 281 – 285 .

23. Kwai Ben I , Elliot D . “ Venting ” or partial lateral release of the A2 and A4 pulleys after repair of zone II fl exor tendon injuries . J Hand Surg (Br) . 1998 ; 23 : 649 – 654 .

24. Al-Qattan MM , Al-Turaiki TM . Flexor tendon repair in zone 2 using a six-strand ‘ fi gure of eight ’ suture . J Hand Surg (Eur) . 2009 ; 34 : 322 – 328 .

25. Giesen T , Sirotakova M , Copsey AJ , et al . Flexor pollicis longus primary repair: further experience with the Tang technique and controlled active mobilisation . J Hand Surg (Eur) . 2009 ; 34 : 758 – 761 . This clinical study reported the most up-to-date clinical outcomes of repairs of lacerated fl exor pollicis longus (FPL) tendons from a renowned center dealing with fl exor tendon injuries. These authors have made a series of reports of their results in treating FPL injuries over the past two decades; this most recent report documents their outcomes in 50 FPL injuries. With a six-strand core tendon repair alone (without peripheral repairs), they achieved good or excellent functional recovery in 80% of thumbs, with zero tendon rupture with an active motion regime. These are the best clinical results of FPL tendon repairs reported thus far. It is worth noting that the authors did not elaborate peripheral sutures in these FPL tendon repairs, and the oblique pulley in the thumb was vented to accommodate tendon repairs.

26. Manske PR . History of fl exor tendon repair . Hand Clin . 2005 ; 21 : 123 – 127 .

27. Mason ML , Shearon CG . The process of tendon repair. An experimental study of tendon suture and tendon graft . Arch Surg . 1932 ; 25 : 615 – 692 .

28. Salomon A . Klinische und experimentelle Untersuchungen ü ber Heilung von Schnenverletzungen insbesondere innerhalb der Sehnenscheiden Arch Klin Chir . 1924 ; 129 : 397 .

29. Salomon A . Ueber den Ersatz grosser Sehnendefekte durch Regeneration . Arch Klin Chir . 1919 ; 113 : 30 .

30. Bunnell S . Repair of tendons in the fi ngers and description of two new instruments . Surg Gynecol Obstet . 1918 ; 26 : 103 – 110 .

31. Bunnell S . Repair of tendons in the fi ngers . Surg Gynecol Obstet . 1922 ; 35 : 88 – 97 .



32. Garlock JH . Repair of wounds of the fl exor tendons of the hand . Ann Surg . 1926 ; 83 : 111 – 122 .

33. Mason ML . Primary and secondary tendon suture. A discussion of the signifi cance of technique in tendon surgery . Surg Gynecol Obstet . 1940 ; 70 : 392 – 402 .

34. Lexer E . Did Verwehtung der freien Schnenstransplantation . Arch Klin Chir . 1912 ; 98 : 818 – 825 .

35. Mayer L . The physiological method of tendon transplantation. I. Historical, anatomy, and physiology of tendons . Surg Gynecol Obstet . 1916 ; 22 : 182 – 197 .

36. Mayer L . The physiological method of tendon transplantation. II. Operative technique . Surg Gynecol Obstet . 1916 ; 22 : 298 – 306 .

37. Mayer L . The physiological method of tendon transplantation. III. Experimental and clinical experiences . Surg Gynecol Obstet . 1916 ; 22 : 472 – 481 .

38. Pulvertaft RG . Repair of tendon injuries in the hand . Ann R Coll Surg Engl . 1948 ; 3 : 3 – 14 .

39. Graham WC . Flexor tendon grafts to the fi nger and thumb . J Bone Joint Surg (Am) . 1947 ; 29 : 553 – 559 .

40. Littler JW . Free tendon grafts in secondary fl exor tendon repair . Am J Surg . 1947 ; 74 : 315 – 321 .

41. Boyes JH . Why tendon repair? J Bone Joint Surg (Am) . 1959 ; 41 : 577 – 579 .

42. Boyes JH , Stark HH . Flexor-tendon grafts in the fi ngers and thumb. A study of factors infl uencing results in 1000 cases . J Bone Joint Surg (Am) . 1971 ; 53 : 1332 – 1342 . This classic article reported perhaps the largest case series of free tendon grafting in the fi ngers and thumbs. The authors analyzed the factors infl uencing the prognosis for free tendon grafting and showed that the tendon-grafting procedure used can produce clinically acceptable function. However, hand conditions are extremely important. Prognostic factors include conditions of the soft tissues and joints. Extensively scarred tendon bed and joint damage led to the worst prognosis after tendon graft surgeries.

43. Mayer L . Celloidin tube reconstruction of extensor communis sheath . Bull Hosp Joint Dis Orthop Inst . 1940 ; 1 : 39 .

44. Bassett CAL , Carroll RE . Formation of tendon sheaths by silicone rod implants. Proceedings of American Society for Surgery of the Hand . J Bone Joint Surg (Am) . 1963 ; 45 : 884 .

45. Hunter JM . Artifi cial tendons. Early development and application . Am J Surg . 1965 ; 109 : 325 .

46. Hunter JM , Salisbury RE . Flexor-tendon reconstruction in severely damaged hands. A two-stage procedure using a silicone-Dacron reinforced gliding prosthesis prior to tendon grafting . J Bone Joint Surg (Am) . 1971 ; 53 : 829 – 852 .

47. Manske PR , Bridwell K , Lesker PA . Nutrient pathways to fl exor tendons of chickens using tritiated proline . J Hand Surg (Am) . 1978 ; 3 : 352 – 357 .

48. Manske PR , Bridwell K , Whiteside LA , et al . Nutrition of fl exor tendon in monkeys . Clin Orthop Relat Res . 1978 ; 136 : 294 – 298 .

49. Manske PR , Lesker PA . Nutrient pathways of fl exor tendons in primates . J Hand Surg (Am) . 1982 ; 7 : 436 – 447 .

50. Manske PR , Lesker PA . Comparative nutrient pathways to the fl exor profundus tendons in zone II of various experimental animals . J Surg Res . 1983 ; 34 : 83 – 93 .

51. Matthew P . The fate of isolated segments of fl exor tendons within the digital sheath . Br J Plast Surg Br . 1976 ; 28 : 216 – 224 .

52. Matthews P , Richards H . The repair reaction of fl exor tendon within the digital sheath . Hand . 1975 ; 7 : 27 – 29 .

53. Matthews P , Richards H . Factors in the adherence of fl exor tendons after repair . J Bone Joint Surg (Br) . 1976 ; 58 : 230 – 236 .

54. Matthew P . The fate of isolated segments of fl exor tendons within the digital sheath . Br J Plast Surg . 1976 ; 28 : 216 – 224 .

55. Lindsay WK , Thomson HG . Digital fl exor tendons: an experimental study (part I). The signifi cance of each compartment of the fl exor mechanism in tendon healing . Br J Plast Surg . 1959 ; 12 : 289 – 316 .

56. Lindsay WK , Thomsonab HG , Walkerab FG . Digital fl exor tendon: an experimental study (part II). The signifi cance of a gap occurring at the line of suture . Br J Plast Surg . 1960 ; 13 : 1 – 9 .

57. Lindsay WK , McDougall EP . Digital fl exor tendons: an experimental study (part III). The fate of autogenous digital fl exor tendon grafts . Br J Plast Surg . 1961 ; 13 : 293 – 304 . [58]

58. Manske PR , Lesker PA . Histological evidence of fl exor tendon repair in various experimental animals. An in vitro study . Clin Orthop Rel Res . 1984 ; 182 : 353 – 360 .

59. Manske PR , Lesker PA . Biochemical evidence of fl exor tendon participation in the repair process – an in vitro study . J Hand Surg (Br) . 1984 ; 9 : 117 – 120 .

60. Gelberman RH , Manske PR , Vande Berg JS , et al . Flexor tendon healing in vitro : comparative histologic study of rabbit, chicken, dog and monkey . J Orthop Res . 1984 ; 2 : 39 – 48 .

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